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SURGICAL   DISEASES  AND   INJURIES  OF 
THE  GENITO-URINARY  ORGANS 


Surgical   Diseases   and 

Injuries  of  the 
Genito -Urinary  Organs 


By 

J.  W.  Thomson  Walker 

M.B.,   C.M.Ed.,    F.R.C.S.Eng. 

Hunterian  Professor  of  Surgery  and  Pathology,   Royal  College  of  Surgeons 

of  England    (1907)  ;   Surgeon   to   the   Hampstead   General   and   North-West 

London    Hospital;    Assistant-Surgeon   to   St.    Peter's   Hospital   for  Stone; 

Urinary  Surgeon  to  the  Radium  Institute. 


With  24  Colour  and  21  Black-and-White 
Plates,  and  279  Illustrations  in  the  Text 


NEW    YORK 
FUNK    &    WAGNALLS    COMPANY 


t  .z- 


3: 

T 


PREFACE 

In  the  following  pages  I  have  given  an  account  of  the 
diseases  and  injuries  of  the  urinary  system,  and  of  the  male 
genital  system,  which  I  hope  will  prove  of  value  to  members 
of  the  profession  engaged  in  general  practice,  and  may  also  assist 
those  on  the  threshold  .of  a  surgical  career. 

A  textbook  should  reflect  the  current  opinion  of  the  day,  and 
should  at  the  same  time  bear  the  impress  of  the  experience 
and  individual  views  of  the  author.  I  have  endeavoured  to  give 
each  its  proper  place  in  this  volume. 

For  the  benefit  of  those  anxious  to  obtain  a  more  extensive 
knowledge  of  any  subject,  a  few  references  to  recent  articles  from 
the  literature  of  different  countries  have  been  provided.  Many 
valuable  articles  have  of  necessity  been  omitted  from  these  lists, 
but  references  to  these  may  be  obtained  through  the  channels  I 
have  quoted. 

In  writing  these  pages  I  have  drawn  largely  on  my  own  expe- 
rience and  have  referred  to  many  personal  cases.  Many  procedures 
which  are  of  merely  historical  interest  have  been  omitted,  and 
space  has  thus  been  found  for  a  more  adequate  discussion  of 
modern  methods. 

The  claims  of  a  pathological  as  opposed  to  an  anatomical 
classification  of  diseases  have  received  full  consideration. 

I  decided  to  retain  the  anatomical  classification  for  the  reason 
that  this  work  lays  no  claim  to  be  a  purely  scientific  treatise  on 


VI 


PREFACE 


the  diseases  of  tlie  genito-urinary  organs,  but  is  intended  to 
serve  as  an  aid  to  clinical  work;  and  my  personal  experience 
of  using  textbooks  arranged  in  the  anatomical  and  in  the 
pathological  classification  is  that  it  is  easier  to  refer  to  the 
former  in  an  obscure  case  than  to  the  latter. 

In  recent  works  there  is  observable  a  tendency  to  slur  over 
the  science  and  to  make  prominent  the  art  of  urinary  surgery. 
With  this  I  am  not  in  sympathy.  It  is,  I  believe,  impossible  to 
carry  out  good  work  on  a  superficial  knowledge  of  the  patho- 
logical conditions  with  which  the  surgeon  has  to  deal. 

The  pathology  given  in  the  following  pages  is  not  the  pathology 
of  the  post-mortem  room.  It  is  the  Hving  pathology  met  with 
by  the  surgeon  in  the  operating  theatre,  and,  as  such,  is  of  vital 
importance  to  proper  treatment. 

Special  attention  has  been  paid  to  both  the  immediate  and 
the  late  results  of  operation,  and,  whenever  possible,  reliable 
statistics  in  regard  to  these  have  been  given.  This  will,  I  hope, 
prove  of  value  to  the  practitioner  in  considering  the  question  of 
prognosis. 

The  illustrations,  with  very  few  exceptions,  are  from  cases 
that  have  been  imder  my  care,  or  from  specimens  that  have  been 
removed  by  operation. 

Professor  A.  K.  Ferguson,  of  Cairo,  generously  provided  a 
series  of  beautiful  microscopical  sections  illustrating  bilharziosis, 
from  which  Pigs.  121,  122,  and  123  were  drawn.  To  him  and  to 
Professor  F.  C.  Madden,  who  also  helped  me  in  this  section,  I 
wish  to  express  my  warmest  thanks. 

The  cystoscopic  drawings  are,  I  believe,  of  exceptional  value. 
They  were  obtained  direct  from  the  patient,  and  are  chosen 
from  a  large  collection  made  during  a  number  of  years.  For 
these    and  for   manv  other   illustrations    I   have   to   thank   the 


PREFACE  vii 

patience  and  skill  of  Mr.  Thornton  Shiells.  To  Dr.  G.  Dupuy  my 
thanks  are  due  for  his  skilful  realism  in  drawing  the  ilhistrations 
of  operations. 

I  have  to  express  my  gratitude  to  my  friend  Sydney 
G.  MacDonald,  F.R.C.S.,  who  undertook  the  arduous  task  of 
reading  proofs,  and  to  whom  I  am  indebted  for  many  valuable 
suggestions. 

To  my  publishers  I  ofier  my  especial  thanks  for  the  generous 
enthusiasm  with  which  my  suggestions  in  regard  to  the  illustra- 
tions of  the  volume  were  adopted,  and  for  their  forbearance  in 
many  delays. 

J.  W.  THOMSON  WALKER. 

Jantiary,   1914. 


CONTENTS 


Part  I. — The  Kidney 

CIIAP'TER 

1.  Surgical  Anatomy     ....... 

2.  Physiology  and  Pathology  of  the  Renal  Function 

3.  Examination  of  the  Kidneys    ..... 

4.  Abnormal  Conditions  of  the  Urine 

5.  Congenital  Abnormalities  of  the  Kidney  and  Ureter 

6.  Movable  and  Floating  Kidney  .... 

7.  Injuries  of  the  Kidney    ...... 

8.  Aneurysm  of  the  Renal  Artery       .         .         .         . 
.9.  Perinephritis  and  Perinephritic  Abscess 

10.  Surgical  Inflammation  of  the  Kidney  and  Pelvis 


11.  Surgical  Inflammation  of  the  Kidney 

(concluded)        ..... 

12.  Hydronephrosis         .... 

13.  Tumours  of  the  Kidney  and  Ureter 

14.  Cysts  of  the  Kidney 

15.  Perirenal  and  Suprarenal  Tumours 

16.  Infective  Diseases    .... 

17.  Renal  Calculus         .... 

18.  Calculous  Anuria     .... 

19.  Oper.\tions  on  the  Kidney 

ix 


AND  Pelvis 


I 

10 

31 

47 

67 

78 

96 

109 

III 

116 

138 
164 
186 
207 
220 
226 
249 
278 
284 


X  CONTENTS 

Part  II.— The   Ureter 

CHAPTER 

20.  Surgical  Anatomy — Physiology — Examination 

21.  Injuries  of  the  Ureter    .         .         .         .         .         . 

22.  Congenital  Abnormalities  of  the  Ureter — Prolapse 

— Fistula        ........ 

23.  Stone  in  the  Ureter    .    .    .    .    . 

24.  Operations  on  the  Ureter   ..... 


PAGE 
299 

^.08 


312 

334 


Part   III.— The   Bladder 

25.  Surgical  Anatomy  and  Physiology 

26.  Examination  of  the  Bladder   . 


z^j.  Methods   of   collecting  the   Urine 
THE  Function  of  each  Kidney 


28.  Vesical  Symptoms  of  Disease    . 

29.  Congenital  Malformations 

30.  Cystocele — Prolapse — Diverticula 

31.  Injuries  of  the  Bladder 

32.  Cystitis      ..... 

33.  Tuberculous  Cystitis 

34.  Other  Infections  of  the  Bladder 

35.  Tumours  of  the  Bladder 

36.  Vesical  Calculus 

37.  Foreign  Bodies  in  the  Bladder 

38.  Pericystitis  and  Perivesical  Abscess 

39.  Fistula  of  the  Bladder  and  Perivesical  Hydatid 

Cysts      .         .         .         .         .         .         . 

40.  Nervous  Diseases  of  the  Bladder  .         .         .         . 

41.  Operations  on  the  Bladder      ,         .         .         .         . 


AND     examining 


344 

352 

367 
374 
392 
405 
416 

423 
437 
445 
454 
490 

514 
517 

522 
531 
541 


CONTENTS 
Part    IV.— The    Urethra 

CHAI'TEK 

42.  Surgical  Anatomy     .         .         .  •       .         ... 

43.- Examination    of    the    Urethra — Urethral   Shock- 
Urethral  Fever     ..... 

44.  Congenital  Malformations  of  the  Urethra 

45.  Prolapse  of  the  Urethra — Urethrocele 

46.  Injuries  of  the  Urethra 

47.  Urethritis         ..... 

48.  Urethral  Calculus — Foreign  Bodies 

49.  Stricture  of  the  Urethra 

50.  Periurethritis — Urethral  Fistula   . 

51.  Growths  of  the  Urethra 

52.  Tuberculosis  of  the  Urethra  and  Penis 


XI 

I'Acnc 

555 

569 
585 
588 

595 
618 
623 
647 
656 
665 


Part  v.— The  Prostate 

53.  Surgical  Anatomy — Examination — Congenital  Mal- 

formations     ..... 

54.  Prostatitis    ..... 

55.  Tuberculosis  of  the  Prostate 

56.  Simple  Enlargement  of  the  Prostate 

57.  Atrophy  of  the  Prostate 

58.  Malignant  Disease  of  the  Prostate 

59.  Calculus  of  the  Prostate 


667 

677 
685 
690 
728 
731 
739 


Part   VI. — The    Seminal   Vesicles   and   Cowper's   Glands 

60.  Anomalies  and  Affections  of  the  Seminal  ^^esicles 

— Cowper's  Glands  ......     744 


xii  CONTENTS 

Part  VII.— The  Testicle 

CHAPTER 

6i.  Anatomy  and  Malformations — Injuries  and  Wounds 
— Torsion       .         .         ... 

62.  Congenital    Malposition — Imperfectly    Descended 

Testicle — Ectopia  Testis        .... 

63.  Inflammation  of  the  Epididymis  and  Testicle 

64.  Syphilis  of  the  Epididymis  and  Testicle 

65.  Tuberculosis  of  the  Epididymis  and  Testicle 

66.  New  Growths  of  the  Testicle 

67.  Impotence  and  Sterility  . 


753 

761 
771 

778 
781 
789 

797 


Part   VIII. — The  Tunica   Vaginalis 

68.  Hydrocele  and  Hematocele — New  Growths   .         .     800 

Part   IX. — ^The   Spermatic   Cord 

69:  Volvulus  —  Hydrocele      and      Hematocele  —  New 

Growths — Varicocele    .         .         .         .         .         .     819 

Part  X. — The   Scrotum 

70.  Elephantiasis — New  Growths 828 

Part   XL— The   Penis 

71.  Anatomy — Congenital    Malformations — Injuries— 

Preputial  Calculi  ......     834 

72.  Balanitis— Herpes    Preputialis — (Edema    of    Penis 

— Priapism — Fibrous    Cavernositis — ^Tumours         .     844 

INDEX   .         . .     863 


LIST   OF   PLATES 

FACING    I'AHK 

Plate  1  ..........        38 

Fig.  I. — Shadow  thrown  by  Gall-Stone  in  Renal  Area. 
Fig.  2. — Shadows  thrown  by  Bismuth-covered  F^ces. 
Fig.  3. — Shadow     thrown     by     Intra-Abdominal     Cal- 
careous Glands. 

Plate  2....... -..42 

Fig.  I. — Pyelography  :       Injected     Pelvis     showing 

DicHOTOMOus  Outline  and  Calyces. 
Fig.  2. — Pyelography  :  Collargol  which  has  regurgi- 
tated INTO  Bladder. 
Fig.  3. — ^Pyelography  in  Movable  Kidney. 

Plate  3         .  .  .  .  .  .  ..         .  >         -44 

Fig.  i. — Dilated  Calyces  in  Ureteral  Calculus. 

Fig.  2. — Hydronephrosis    caused    by   Aberrant    Renal 

Vessels. 
Fig.  3. — Hydronephrosis   (Pelvic   Type)   in   Movable 

Kidney. 

Plate  4         .  .  .  .  .  .  .  .  .  .45 

Fig.  I. — ^Double  Hydronephrosis. 

Fig.  2. — Pyelography  :    Normal  Trumpet-shaped  Pelvis 

and  Calyces. 
Fig.  3. — Pyelography  :    Normal  Trumpet-shaped  Pelvis 

AND  Calyces. 

Plate  5  (Colour)    .........       58 

Fig.  I. — Hematuria:    Blood-stained  Efflux  from  Left 
Ureter. 

Fig.  2. — Semi-solid  Pus  issuing  from  Ureter  in  Case  of 
Chronic  Suppurative  Pyelonephritis. 

Plate  6  [Colour)    .         ,  ,  ,  .  .  .  .  .128 

Ascending  Pyelonephritis    in  Case  of  Enlarged  Pros- 
tate. 
*  xiii 


xiv  LIST  OF  PLATES 

FACING    PAGE 

Plate  7  {Colour)    .         .  .  .  .  .  .  .  '       .      132 

Dilatation  of  Renal  Pelvis,  Pyelitis,  and  Suppurative 
Nephritis  in  Enlarged  Prostate, 

Plate  8  ..........  ,  156 

Fig.  I. — Shadows   of   Large   Calculus   in    Kidney   and 
Number  of  Small  Calculi  lying  in  Sponta- 
neously-formed Fistula. 
Fig.  2. — Hydronephrosis     due     to     Adhesions      round 
Vertebra  in  Scoliosis. 

Plate  9        ' .  .  .  .  .  .  .  .  .  .      176 

Fig.  I. — Author's     Method     of     determining     Normal 

Extent    of    Renal    Areas    on    Radiographic 

Plate. 
Fig.  2. — Method  of  measuring  Shadow  of  Kidney. 
Fig.  3. — Shadows    thrown    by    Metastatic    Deposit    in 

Mediastinal  Glands  and  in  Lungs  in  Case  of 

Malignant  Growth  of  Kidney. 

Plate  10   [Colour)  .  .......      192 

Hypernephroma  of  Kidney. 

Plate  11  {Colour)  ........      192 

Section  of  Hypernephroma  of  Kidney. 

Plate  12  {Colour)  .  .  .  .  .  .  ...      222 

Hypernephroma     of     Suprarenal     Capsule     invading 
Kidney. 

Plate  13  {Colour)  .  .  .  .  .  .  .  .      228 

Tuberculosis  of  Kidney,  Ulcero-Cavernous  Type. 

Plate  14  {Colour)  ........      228 

Acute  Tuberculosis  of  Kidney  with  Mixed  Infection 

Plate  15  {Colour)  ........      230 

Tuberculosis    of   Kidney,    Final   Stage  :     Tuberculous 
Hydronephrosis. 

Plate  16  {Colour)  ........     234 

Fig.   I. — Ureteric  Orifice  in  Chronic  Pyelitis. 
Fig.  2. — Tuberculous  Ulceration  of  Ureteric  Orifice. 
Fig.  3. — Dragged-out  Ureter  in  Chronic  Tuberculous 
Ureteritis. 

Plate  17       .  .  .  .  .         =  .  .  .  .     236 

Shadow  thrown  by  Caseous  Tubercle  of  Left  Kidney. 


LIST  OF  PLATES  xv 

r-ACING    TAtiK 

Plate  18  (Colour) 254 

Multiple  Calculi  of  Kidney. 

Plate  19  (Colour) 256 

Renal  Calculus  ;  Dilatation  of  Renal  Pelvis  and 
Pyelitis  ;  Invasion  and  Destruction  of 
Kidney  by  Hypertrophy  of  Fat  in  Renal 
Sinus. 

Plate  20 264 

Fig.  I. — Shadows    of    Large    Branching   Calculus   and 

OF  Two  Smaller  Calculi  in  Kidney. 
Fig.  2. — Shadow    of    Calculi    in    Right    Kidney,    with 
Clear  Field  in  Left  Kidney  Area. 

Plate  21 306 

Fig.  I. — Opaque  Bougie  in  Ureter. 

Fig.  2. — Shadow   of  Calculus    in    Ureter   at   Brim   of 

Pelvis. 
Fig.  3. — Shadows  of  Opaque    Bougies  lying  in  Double 
Ureter. 

Plate  22  (Colour)  .  . 328 

Fig.  I. — Prolapse  of  Ureters. 

Fig.  2. — Right  Ureteral  Orifice  in  Descending  Ure- 
teral Calculus  (Infected). 

Fig.  3. — Descending  Ureteral  Calculus  (Non-Infected). 

Fig.  4. — E version  of  Ureteral  Orifice  Twenty  Minutes 
AFTER  Expulsion  of  Calculus  into  Bladder. 

Fig,  5. — Uric- Acid  Calculus  partly  extruded  from 
Ureteral  Orifice. 

Fig.  6. — Acute  Ureteritis  in  Descending  Calculus. 

Fig.  7. — False  Ureteral  Orifice  produced  by  Ulcera- 
tion OF  Calculus  from  Ureter  into  Bladder. 

Plate  23       .........  .     330 

Fig.   i. — Two  Calculi  in  Right  Ureter. 
Fig.  2. — Oval   Calculus   in    Pel\t:c   Segment    of   Right 
Ureter. 

Plate  24        .  .  .  .  .  .  .  .  .  .     331 

Fig.   I. — Shadows      in      Pelvis      due      to      Calcareous 

Glands. 
Fig.  2. — Shadows    thrown    by    Calcareous    Glands    in 

Region  of  Pelvis  and  Ureter  on  Right  Side. 
Fig.  3. — Shadow  thrown  by  Calcareous  Gland  outside 

Line  of  Right  Ureter. 


xvi  LIST  OF  PLATES 

FACING    PAGE 

Plate  25        .........  .      332 

Fig.  I. — Shadows  thrown  by  Calcareous  Glands  below 

AND  internally  TO  LeFT  KiDNEY. 

Fig.  2.— Shadow  of  Large  Oval  Calculus  in  Pelvic 
Segment  of  Left  Ureter,  and  of  Opaque 
Bougie  lying  beside  it. 

Fig.  3. ^Calculus  in  Pel\t:c  Segment  of  Ureter,  and 
Opaque  Bougie  lying  in  Ureter. 

Plate  26        .........  .     333 

Fig.  i. — Ureteral  Calculus  lying  in  Pelvic  Segment, 

Cystoscope  in  Bladder,  and  Opaque  Bougie 

IN  Ureter. 
Fig.  2. — ^Two   Calculi   lying  at   Lower   End   of   Right 

Ureter. 

Plate  27 360 

Fig.  i. — Shadow  thrown  by  Partly  Distended  Healthy 

Bladder. 
Fig.  2. — Shadow  of  Greatly  Distended  Bladder  and  of 

Diverticulum  ;   Catheter  lying  in  Urethra. 
Fig.  3. — Shadow  of  Ureteral  Calculus  in  Middle  Line 

OF  Bladder. 

Plate  28 361 

Fig.  I. — Shadow   of  Phosphatic   Calculus   in   Bladder 

pushed  to  Right  of  Middle  Line  by  Large 

Growth  on  Left  Side  of  Bladder. 
Figs.  2,  3. — Calculus  in  Bladder  which  was  moved   to 

Left  of  Middle  Line  from  Patient  lying  on 

Left  Side. 

Plate  29 362 

Fig.  I. — Shadow    of    Large    Phosphatic    Calculus    in 

Diverticulum  of  Bladder. 
Fig.  2. — Shadows  in  Pelvis. 
Fig.  3. — Diverticulum  of  Bladder. 
Plate  30  {Colour)  .........      412 

Fig.  I. — Orifice    of   Diverticulum   and    Trabeculation 

ON  Posterior  Wall  of  Bladder. 
Fig.  2. — Orifice    of   Large    Diverticulum    of   Bladder 

CLOSE  TO  Right  Ureteral  Orifice. 
Fig.  3. — Partial  Rupture  of  Bladder  :   Appearance  of 

Mucous  Membrane  Six  Days  after  Accident. 


LIST  OF   PLATES  xvii 

FACING    PACE 

Plate  31  (Colour)  .........     426 

Fig.  i.^ — Acute  Cystitis. 
Fig.  2. — Cystic  Cystitis. 
Fig.  3. — Ulcer  of  Bladder  in  Cystitis  due  to  Bacillus 

coLi  communis. 
Fig.  4. — Tuberculosis  of  Bladder  :    Group  of  Caseous 

Tubercles. 
Fig.  5. — Tuberculous   Ulcer   with    Caseous   Tubercles 

in  Vicinity. 

Plate  32  (Colon i^) 446 

Fig.  i. — Bilharzial  Nodules  in  Bladder. 
Fig.  2. — Bilharzial  Granulations  in  Bladder. 
Fig.  3. — Villous  Papilloma  of  Bladder. 

Plate  33        .........  .     472 

Figs,  i,  2,  3. — Views  of  Operation  Specimen  of  Malig- 
nant Growth  of  Bladder  (Nodular  Papilloma). 

Fig.  4. — Recurrence  of  Malignant  Growth  of  Bladder 
IN  Scar  of  Resection  Wound. 

Plate  34       .  .........     473 

Operation  Specimen  of  Squamous  Epithelioma  of 
Bladder. 

Plate  35  (Colour)  ........      47S 

Fig.  I. — Nodul.ar  Malignant  Growth  of  Bladder. 
Fig.  2. — Nodular  Malignant  Growth  of  Bladder  with 

Necrotic  Surface. 
Fig.  3. — Small  Nodular  Malignant  Growth  of  Bladder. 

Plate  36  (Colour)  ........     500 

Fig.  i. — Large  Phosphatic  Calculus  with  Cystitis. 
Fig.  2. — Uric- Acid   Calculi   covered  with   Thin   Layer 

OF  Phosphates. 
Fig.  3. — OxALATE-OF-LiME  Calculi  in  Bladder. 

Plate  37 504 

Fig.  i. — Shadow  of  Calculus  in  Grasp  of  Lithotrite. 
Fig.  2. — Shadow  of  Evacuating  Cannula. 

Plate  38  (Colour)  .  .  .  .  .  .  .  -514 

Fig.  i. — Stud  -  Buttoner     covered     with     Phosphatic 

Deposit  in  Male  Bladder. 
Fig.  2. — DouBLED-up  Piece  of  Wax  in  Male  Bladder. 
Fig.  3. — Atrophy  of  Bladder  Wall  in  Tabes  Dorsalis. 


xviii  LIST  OF  PLATES 

FACING    PAGE 

Plate  39        .  .  .  .  .  .  .  ...      590 

Fig.  I. — Pelvic  Shadow  after  Fracture  of  Pelvis  and 

Rupture  of  Urethra. 
Fig.  2. — Stone  in  Fossa  Navicularis  of  Urethra. 

Plate  40  {Colour)  ........     626 

Fig.  I. — ^Lacun^    and    Striation    of    Roof    of    Normal 

Urethra. 
Fig.  2. — Scar  Tissue  in  Urethra  in  Old-standing  Stric- 
ture. 
■  Fig.  3.^Urethroscopic  View  of  Stone  behind  Stricture 
OF  Urethra. 
Fig.  4. — Urethroscopic  View  of  Stricture  with  Large 
False    Passage    on    Floor   and   another   on 
Roof  of  Urethra. 

Plate  41  {Colour)  ........     660 

Fig.   I.— Papilloma  of  Anterior  Urethra. 

Fig.  2. — Polypus    of   Posterior   Urethra   attached    to 

Premontanal  Ridge. 
Fig.  3. — Urethroscopic  View  of  Polypus  of  Urethra. 
Fig.  4. — Malignant     Growth     of     Anterior     Urethra 

appearing  through  a  Stricture. 

Plate  42       .........  .     742 

Fig.  I. — Shadow  of  Large  Single  Prostatic  Calculus. 
Fig.  2. — Shadows  of  Small  Irregular  Scattered  Pros- 
tatic Calculi. 

Plate  43  {Colour)  ........     778 

Gumma  of  Testicle  ulcerating  on  Surface  of  Scrotum. 

Plate  44  {Colour)  .  .  .  .  .  .  .  .     782 

Tuberculosis  of  Epididymis  with  Tuberculous  Abscess 
under  Skin  of  Scrotum  and  Miliary  Tubercle 
OF  Testicle. 

Plate  45  {Colour)  ........     792 

Solid  Embryoma  of  Testicle  ;    Operation  Specimen. 


SURGICAL   DISEASES  AND   INJURIES 
OF    THE  GENITO-URINARY  ORGANS 

PART  L—THE  KIDNEY 

CHAPTER  I 

SURGICAL  ANATOMY 

Situation  of  the  kidney. — The  kidneys  lie  obliquely  on  the 
posterior  wall  of  the  abdomen,  the  upper  end  of  each  being  2| 
cm.,  the  hilum  3J  cm.,  and  the  lower  pole  4  cm.  from  the  middle 
line.     The  anterior  surface  has  an  antero -external  aspect. 

The  upper  border  of  the  kidney  corresponds  to  the  middle  of 
the  11th  dorsal  vertebra,  and  the  lower  border  to  the  lower  border 
of  the  transverse  process  of  the  3rd  lumbar  vertebra  about  5  cm. 
above  the  iliac  crest.  The  left  kidney  reaches  to  the  upper  border 
of  the  same  process.  The  hilum  of  the  kidney  corresponds  to 
the  2nd  lumbar  vertebra.  The  upper  two-thirds  of  the  kidney 
lies  under  cover  of  the  11th  and  12th  ribs,  the  lower  one-third 
descends  below  them.  The  12th  rib  may,  rarely,  be  absent ;  it 
may  be  short  and  only  come  into  relation  with  a  small  part  of 
the  posterior  surface  of  the  kidney,  or  it  may  be  long  and  project 
beyond  it.  A  short  12th  rib,  less  than  7  cm.  long,  is  always 
horizontal  ;    a  longer  rib  is  oblique. 

Relations  of  the  kidney  (Figs.  1,  2). — The  posterior  rela- 
tions are  the  diaphragm,  and  the  anterior  layer  of  the  trans- 
versalis  aponeurosis  which  separates  it  from  the  quadratus 
lumborum  muscle.  A  strong  process  of  this  aponeurosis,  the 
costo-vertebral  ligament,  reaches  from  the  tips  of  the  transverse 
processes  of  the  1st  and  2ud  lumbar  vertebrae  to  the  12th  rib. 
Between  the  fibres  of  origin  of  the  diaphragm  from  the  external 
arcuate  ligament  and  the  r2th  rib  the  pleura  is  uncovered  and 
comes  into  relation  with  the  kidney.     The  psoas  muscle  is .  also 


THE   KIDNEY 


[chap. 


related  to  a  small  part  of  the  kidney  at  its  lower  pole.  The  more 
important  structures  met  with  in  exposing  the  kidney  from  the 
lumbar  aspect  are  as  follows  :  the  skin,  subcutaneous  fascia  and 
fat,  the  latissimus  dorsi  muscle  and  the  external  oblique,  the 
serratus  posticus  inferior,  internal  oblique,  the  lumbar  fascia, 
the  12th  intercostal  nerve  and  vessels,  the  perirenal  fascia  and 
perirenal  fat. 

The  anterior  surface  of  the  right  kidney  is  covered  by  peri- 
toneum along  the  outer  border  and  upper  part  of  its  surface.  At 
the  upper  part  it  is  in  relation  to  the  under  surface  of  the  right 


SHORT   /Z'^^RIB 


£XT£RN/iL 

/^RCU/^TE 

LIG/iMENT 


QU/iDRATUS 
I  UMBO RUM 


ILIAC  CREJT 


'ERE.CTOR     SPINA  E 


Fig.  1. — Diagram  of  the  general  relations  of  the  kidneys. 

lobe  of  the  liver  and  internally  to  the  vena  cava.  The  hepatic 
flexure  of  the  colon  crosses  the  lower  one-third  and  is  adherent 
to  it.  In  this  situation  a  nephro-colic  ligament  has  been  de- 
scribed. The  descending  part  of  the  duodenum  is  in  direct  contact 
with  an  area  along  the  inner  border,  and  the  common  bile-duct  is 
in  close  relation  to  the  inner  border  of  the  organ.  In  relation  to 
the  anterior  surface  of  the  left  kidney,  and  separated  from  it  by 
peritoneum,  are  the  stomach  and  spleen,  the  former  lying  in  con- 
tact with  the  upper  pole  and  the  latter  with  an  area  along  the 
outer  border.  Below  the  stomach  area  the  tail  of  the  pancreas 
and  the  splenic  artery  are  in  contact  with  the  kidney.  The 
duodeno-jejunal  junction  is  related  to  the  inner  border  at  the 
region  of  the  hilum.     Below  this  the  splenic  flexure  of  the  colon 


Ij 


SURGICAL  ANATOMY 


crosses  the  kidney  and  passes  down  its  outer  border,  and  tlie  left 
colic  artery  lies  upon  its  anterior  surface.  It  is  attached  to  the 
diaphragm  above  and  outside  the  kidney  by  the  phreno-colic 
ligament.  At  the  lower  pole,  iu'  the  angle  formed  by  the  flexure 
of  the  colon,  the  coils  of  small  intestine  are  separated  from  the 
kidney  by  peritoneum. 

The  suprarenal  capsules  are  in  contact  with  the  upper  pole 
of  each  kidney  and  attached  to  it  by  areolar  tissue.  The  con- 
nection is  not  very  firm  in  normal  kidneys,  and  diminishes  with 
age ;   in  disease  of  the  kidney  it  may  be  densely  adherent. 


Diagram  of  the  anterior  relations  of  the  kidneys. 


1  and  2,  Peritoneum-covered  surface  of  right  kidney  in  apposition  with  liver  and  with  small 
intestine  ;  3  and  5,  peritoneum-covered  surface  of  left  kidney  in  apposition  with  stomach,  with 
spleen,  and  with  small  intestine  ;  6,  duodenum  ;  7,  duodeno-jejunal  junction  ;  8,  hepatic 
flexure  of  colon;  9,  ascending  colon;  10.  splenic  flexure;  11,  descending  colon;  12,  attachment 
of  transverse  mesocolon;  13,  suprarenals  ;  14,  gastric  surface  of  spleen;  15.  splenic  vessels; 
16,  pancreas  ;  17,  inferior  vena  cava  ;  18,  aorta  ;  19,  superior  mesenteric  artery  ;  20,  superior 
mesenteric  vein  ;  21.  ureters. 

Investment  of  the  kidney. — The  kidney  lies  embedded  in 
a  layer  of  fine  fat,  the  fatty  capsule,  contained  in  a  fascial  en- 
velope, the  fascia  propria  or  perirenal  fascia.  (Figs.  3,  4.)  The 
perirenal  fascia  appears  between  the  transversalis  fascia  and  peri- 
toneum, and  divides  into  an  anterior  and  a  posterior  layer  at  the 
border  of  the  kidney.  The  anterior  layer  covers  the  front  of  the 
kidney  and  crosses  the  middle  line  to  join  the  corresponding  layer 
of  the  opposite  side,  passing  in  front  of  the  abdominal  aorta  and 
inferior  vena  cava.  A  thin  layer  splits  off  at  the  hilum  and  covers 
the  renal  blood-vessels.  The  posterior  layer,  or  fascia  of  Ziicker- 
kandl,  lies  behind  the  kidney,  and,  after  sending  a  layer  to  the 


THE   KIDNEY 


[chap. 


PLEURA 


■DMPHRAdM 


renal  vessels,  passes  on  to  be  attached  to  the  sides  of  the  bodies  of 
the  vertebrae.  At  the  upper  pole  of  the  kidney  the  layers  unite 
after  having  enclosed  the  suprarenal  capsule,  and  are  attached  to 
the  under  surface  of  the  diaphragm,  forming  a  suspensory  ligament. 
At  the  lower  pole  the  anterior  layer  is  continued  onwards,  lining 
the  peritoneum,  and  the  posterior  layer  is  gradually  lost  in  the 
extraperitoneal  fat  without  uniting  with  the  anterior  layer. 

The  perirenal  fascia  thus  forms   an   envelope   which   is  open 
on  its  internal  and  inferior  aspects.     It  is  strengthened   by  an 

additional  covering  of 
fascia,  the  fascia  of 
Toldt,  which  is  dis- 
tributed between  the 
fascia  propria  and 
the  hepatic  flexure  of 
the  colon  and  the  de- 
scending part  of  the 
duodenum  on  the  right 
side,  and  the  splenic 
flexure  of  the  colon  on 
the  left  side. 

The  kidney  is  im- 
mediately surrounded 
by  a  fine  layer  of 
fibrous  tissue  in  which 
are  some  non-striped 
muscle  fibres.  This 
capsule  passes  in  at 
the  hilum  to  become 
continuous  with  the 
outer  layer  of  the  pel- 
vis of  the  kidney,  and 
also  invests  the  renal 


SUPRARENAL 
CAPSULE 


POSTERIOR.  LAYER 
Of  PERIREHAL 
FASCIA 


ILI^C    CREST 


PERITONEUM 

ANTERIOR    LAYER 
OF  PERIRENAL 

FASCIA 


KIDNEY 


Fig.  3. — Diagram  of  the  arrangement  of 
the  perirenal  fascia  in  vertical  section. 


vessels.  The  capsule  is  easily  stripped  from  the  kidney  as  far  as 
the    hilum. 

From  the  outer  surface  of  this  capsule  a  network  of  fine  fibres 
passes  out  in  all  directions  to  the  perirenal  fascia.  In  the  meshes 
of  this  is  deposited  a  layer  of  fine  yellow  fat — the  fatty  capsule — 
forming  a  bed  in  which  the  kidney  lies.  This  layer  is  thicker  over 
the  posterior  and  outer  aspects  of  the  kidney.  It  does  not  exist 
before  the  tenth  year. 

Structures  at  the  hilum.  The  renal  pelvis  (Fig.  5). — At 
the  level  of  the  lower  end  of  the  kidney  the  ureter  begins  to 
expand  into  a  trumpet-shaped  extremity  which  passes  the  hilum 


Ij 


SURGICAL  ANATOMY 


and  enters  the  sinus  of  the  kidney.     This  is  the  renal  pelvis.     At 
the  junction  with  the  urc^ter  a  narrow  part  may  frequently  be 


POSTERIOR.    L/^YEH 
OF  P£R/R£N/tL    FASCIS 


Fig.  4. — Diagram  of  the  arrangement  of  the  perirenal  fascia  in 
transverse  section  at  the  level  of  the  2nd  lumbar  vertebra. 

seen.  As  it  passes  upwards  the  pelvis  usually  separates  into 
two  primary  divisions — a  smaller  upper  and  a  larger  lower  branch 
— and  each  of  these  separates  into  three  or  more  subdivisions, 


/INTERIOR 

CALYX 


POSTERIOR 
C/^LYX 


POSTERIOR. 

BRANCH  OF 

ARTERY 


VEIN 


ARTERY 


Fig.  5. — Diagram  of  the  arrangement  of  the  structures  at  the 
hilum  in  transverse  section  of  the  kidney. 

called  calyces  (average  number,   nine),   which  receive  the  apices 
of  the  pyramids  of  the  kidney  on  which  open  the  large  collecting 


THE  KIDNEY 


[CHAr. 


Fig.  6. — Tracings  from  collargol  shadow- 
graphs showing  different  types  of  renal 
pelvis  and  variation  in  calyces.  {See 
Plate  2,  Fig.  1,  and  Plate  4,  Figs.  2,  3.) 

«,  Dichotomous  pelvis  ;  6,  simple  pelvis  ;  c,  compound 
branching  pelvis. 


tubes.  Each  calyx  surrounds  two  or  sometimes  tliree  papillie. 
The  calyces  are  arranged  in  an  anterior  and  a  posterior  series. 
Modifications  of  the  primary  division  are  not  uncommon.  (Fig.  6.) 
The  average  capacity  of  the  renal  pelvis  is  about  3|  drachms. 
Distension  of  2  drachms  or  less  in  the  living  subject  causes  pain 

{see  p.  176). 

^^^^  ^L^  The  renal    artery 

,^^K  ^tL  ^^^-     7).  — The     left 

^^^^M  ^k  ^^^  artery  is  1  cm.  shorter 

^^Bw  ^^^^^         ^L^^^k        than  the  right.     Small 

^V  ^^^^^^^     yH^^^^^      branches  are  given  o:S 

^^  ■   .        ^^1^^^^  ^^^^^^     from  the  main  trunk 

|fl^^  ^^^      I  Ti         ■     or    the   primary  divi- 

i^^w  WT  I  I     sions,  which    pass    to 

a  h  ,      the  fatty  capsule  and 

form  a  network  round 
the  kidney.  At  the 
hilum  the  renal  artery 
divides  into  three  or 
four  branches.  Two 
or  three  of  these  pass 
into  the  sinus  in  front  of  the  pelvis,  and  one  passes  behind  it : 
one  of  the  anterior  branches  passes  to  the  upper  pole  and  may 
reach  it  directly  without  entering  the  hilum.  The  retropelvic 
branch  passes  over  the  upper  border  of  the  pelvis  and  runs  down- 
wards under  the  edge  of  the  posterior  lip  of  the  hilum. 

The  branches  further  subdivide  and  enter  the  kidney  at  the 
columns  of  Bertini  between  the  pyramids,  each  pyramid  being 
surrounded  by  four  or  five  arteries.  These  run  alongside  the 
pyramids  and  curve  towards  the  base  of  the  pyramid.  The  arteries 
do  not  anastomose  either  at  the  base  or  around  the  pyramids. 
The  arterial  supply  is  divided  into  an  anterior  and  a  posterior 
system,  which  are  independent,  and  each  branch  of  which  is  a 
terminal  artery.  The  anterior  system  is  larger  than  the  posterior, 
which  is  formed  by  the  single  posterior  primary  branch.  The 
arteries  of  the  kidney  communicate  on  the  surface  of  the  organ 
with  those  of  the  adipose  capsule,  and  through  these  with  the 
diaphragmatic,  lower  intercostal,  and  lumbar  arteries.  This  anas- 
tomosis with  parietal  arteries  is  not  sufficient  to  carry  on  an 
adequate  blood  supply  if  the  renal  artery  is  blocked. 

An  additional  renal  artery  is  present  in  about  20  per  cent,  of 
bodies.  The  accessory  artery  may  arise  from  the  trunk  of  the 
renal  artery,  from  the  aorta,  or  from  one  of  the  parietal  arteries, 
such  as  the  inferior  phrenic.     The  vessel  may  pass  into  the  kidney 


1] 


SURGICAL  ANATOMY 


at  the  hiluni,  or  it  may  enter  the  surface  of  the  kidney  at  the 
upper  or  lower  pole  on  either  the  anterior  or  posterior  surface. 
Such  a  vessel  is  more  frequent  on  the  left  side  and  above  the  normal 
renal  artery.  An  abnormal  renal  artery  may  pass  in  front  of  or 
behind  the  ureter.  When  the  kidneys  are  abnormal  in  shape 
and  position  an  abnormal  blood  supply  is  very  common.  Irregu- 
larities in  the  veins  are  also  common.  The  surgical  importance 
of  these  abnormalities  lies  in  the  facts  that  in  nephrectomy  an 
abnormal  vessel  may  escape  ligature  and  cause  serious  hsemor- 


ANTERIOR 


REN/^L   y£/NS 


ANTERIOR. 
BRANCHES    Of 
RENAL  ARTERY 


FAT  IN  SINUS 
OF  KIDNEY 


POSTERIOR 


POSTERIOR 

BRANCH    OF 
RENAL  ARTERY 


PELyiS  OF  KIDNEY 


Fig,  7. — Diagram  of  the  relations  of  the  veins,  arteries,  and  pelvis 
at  the  hilum  of  the  kidney.  A  cornice  of  kidney  tissue  has 
been  cut  away  to  display  these  structures. 

rhage,  and  that  hydronephrosis  may  result  from  pressure  of  the 
vessel  on  the  ureter.  In  my  experience,  an  aberrant  artery,  the 
size  of  a  crow-quill,  passing  to  the  upper  pole,  is  very  commonly 
met  with  in  performing  uephrectom3^  The  artery  is  derived  from 
the  suprarenal  or  phrenic  artery. 

On  the  surface  of  the  kidney  the  area  corresponding  to  each 
pyramid  is  usually  marked  out  by  lines  of  paler  colour,  and  a 
depressed  line  can  be  seen  running  parallel  to  the  convex  border 
a  little  in  front  of   its  most   prominent   part.     This  is   BrodeFs 


THE   KIDNEY 


[OHAP. 


line,  and,  with  the  other  pale  areas,  it  indicates  the  lines  along 
which  the  arteries  course.  Brodel's  line  is  the  most  vascular  part 
of  the  kidney,  and  should  for  this  reason  be  avoided  in  incising 
the  organ.  The  least  vascular  line  is  that  which  separates  the 
anterior  and  posterior  arterial  systems  and  runs  parallel  to  and 
a  little  behind  the  curved  border.  This  is  the  exsanguine  line  of 
Hyrtl,  and  is  the  best  line  for  nephrotomy  incision. 

The  rena!  veins  (Fig.  7). — The  small  renal  veins  are  col- 
lected by  large  anastomosing  venous  arches  running  parallel  with 
the  surface  of  the  kidney.     The  veins  emerge  from  the  kidney 


Fig.  8. — Diagram  of  the  lymphatic  vessels  and  glands  of  the 
kidneys,  showing  their  relations  to  the  blood-vessels. 

substance  between  the  papillye  of  the  pyramids  and  anastomose 
between  the  calyces.  Numerous  branches  then  combine  to  form 
two  large  trunks  in  front  of  the  pelvis.  These  and  a  smaller 
posterior  branch  unite  to  form  the  renal  vein.  The  left  renal 
vein  receives  the  spermatic  or  ovarian  vein. 

Lymphatics  of  the  kidney  (Fig.  8). — The  lymphatics  are  col- 
lected into  four  to  seven  large  trunks,  which  emerge  at  the  hilum. 
They  pass  partly  in  front  of  the  vein  and  partly  behind  it,  to  glands 
lying  in  front  of  and  behind  the  vena  cava  on  the  right  side,  and 
alongside  the  aorta  on  the  left  side.  In  their  course  they  run  in 
a  sort  of  mesentery  between  the  layers  of  the  fascia  to  the  glands. 
This  extends  from  the  inner  border  of  the  kidney  and  the  ureter 


I]  SURGICAL  ANATOMY  9 

on  the  outer  side  to  the  aorta  on  the  left  and  the  inferior  vena 
cava  on  the  right  (Gregoire).  They  do  not  anastomose  with  neigh- 
bouring lymphatic  plexuses. 

The  glands  earliest  aft'ected  in  malignant  di.sease  of  the  kidney 
are  found  at  the  hilum  and  lying  along  the  side  of  the  aorta  between 
it  and  the  spermatic  vein,  and  along  the  vena  cava.  These  glands 
lie  in  small  numbers  above  the  renal  vessels  and  in  larger  numbers 
below  them.     The  mediastinal  glands  are  then  the  seat  of  deposit. 

The  renal  pedicle. — The  pedicle  of  the  kidney  consists  of 
the  renal  vein,  the  renal  artery,  the  lymphatic  vessels,  and  the 
nerves,  together  with  a  varying  amount  of  fat.  The  pedicle  is 
about  4  cm.  long.  It  is  shorter  on  the  right  side  than  on  the  left. 
It  is  longer  in  kidneys  which  lie  low  down  and  in  those  which 
show  foetal  lobulation.  When  the  kidney  is  abnormally  movable 
the  pedicle  becomes  elongated,  and  the  organ  in  its  excursion  swings 
downwards  and  towards  the  median  line  round  the  attachment  of 
the  artery  and  the  vein.  When  the  kidney  is  raised  into  a  lumbar 
wound  the  artery  and  vein  are  increased  in  length  by  stretching. 
On  the  right  side  the  wall  of  the  inferior  vena  cava  is  dragged 
outwards,  but  on  the  left  side  the  aoi-ta  is  more  resistant.  The 
pedicle  is  seldom  transverse.  Usually  it  passes  obliquely  upwards 
towards  the  middle  line.  When  the  kidney  is  brought  into  a 
lumbar  wound  this  obliquity  is  increased.  The  circumference  of 
the  pedicle  varies  greatly.  It  is  increased  by  an  early  branching 
of  the  renal  artery,  and  in  diseased  kidneys  may  be  greatly  thick- 
ened by  masses  of  fibrous  fatty  tissue. 

Attachments  of  the  kidney.— The  following  structures 
combine  to  support  the  kidney.  They  prevent  the  organ  from 
being  displaced,  but  allow  it  to  move  freely  (3  to  5  cm.)  with 
respiration . 

1.  The  renal  vessels. 

2.  The  peritoneum. 

3.  The  attachment  of  retroperitoneal    surfaces  of   the  duo- 

denum, colon,  pancreas. 

4.  The  adhesion  to  the  suprarenal  capsule. 

5.  The  perirenal  fascia  and  the  supporting  network  of  fibres 

that  pass  to  it  from  the  renal  capsule. 

6.  The  perirenal  fat. 

7.  The  fascia  of  Toldt. 

8.  The  intra-abdominal  pressure. 


CHAPTER   II 

PHYSIOLOGY   AND  PATHOLOGY   OF   THE 
RENAL  FUNCTION 

The  following  functions  are  combined  in  the  kidney : — 

1.  The  kidneys  separate  from  the  blood  a  fluid  of  different 

molecular  composition,  namely  the  urine. 

2.  They  exercise  a  selective  power  by  which  certain  sub- 

stances are  removed  from  the  blood.     These  substances, 
if  allowed  to  accimiulate  in  the  blood,  produce  uraemia. 

3.  They  have  a  synthetic  action  which  places  them  in  a 

line    with    other-  glandular    organs.     Hippuric    acid    is 
built  up  and  secreted  by  the  kidneys. 

4.  An   internal    secretion    which    affects    nitrogenous    meta- 

bolism is  suggested  by  certain  experiments. 

The  urine  differs  from  the  blood  in  reaction,  in  the  absence  of 
the  proteins  of  the  blood,  in  the  presence  of  hippuric  acid  in  the 
urine,  and  in  the  different  percentage  of  its  constituents. 

The  most  important  factor  in  producing  variations  in  the 
renal  secretion  is  the  velocity  of  the  blood  flow  through  the  organ. 
This  is  affected  by  variations  in  the  general  blood  pressure.  When 
the  aortic  blood  pressure  falls  below  40  cm.  of  mercury  the  flow 
of  urine  stops.  Constriction  of  the  renal  arteries  by  stimulation 
of  the  renal  nerves,  or  pressure  upon  the  renal  artery  so  as  to 
obstruct  its  flow,  and  obstruction  to  the  renal  vein,  diminish  the 
blood  flow  and  reduce  the  secretion  of  urine. 

EXAMINATION    OF    THE   RENAL   FUNCTION 

An  estimate  of  the  function  of  the  kidneys  in  disease  of  these 
organs  may  be  formed  (1)  by  the  discovery  of  symptoms  of  renal 
failure,  (2)  by  an  examination  of  the  urine,  or  (3)  by  certain  tests 
of  the  renal  function. 

1.  Signs  and  Symptoms  of  Renal  Failure 

Pain  is  a  sign  that  the  kidneys  are  diseased,  but  it  is  not  a 
reliable  indication  of  interference  with  the  renal  function.     The 

10 


ciiAi    III  KHNAL  FAILURIt  H 

kidneys  may  hv  the  seat  ol"  a<lvaiic(Hl  disease  and  their  liiiictioM 
sei'ionsly  impaired,  and  the  patient  be  entirely  free  from  pain. 

Thirst,  worst  at  night,  is  tlie  most  frequent  symptom  of  inter- 
ference with  the  renal  f miction.  It  is  marked  in  26-7  per  cent,  of 
cases  of  urinary  obstruction.  The  tongue  early  becomes  dry  (12-9 
per  cent.),  at  first  along  the  centre  and  later  over  the  whole 
surface.  It  has  a  glazed,  cracked  appearance  that  is  distinctive. 
In  tlie  later  stages  of  urinary  septicaemia  the  tongue  is  dry  and 
covered  with  a  brownish  fur  {parrot  tongue).  Loss  of  appetite  is 
constantly  present,  and  in  severe  cases  a  buccal  dysphagia  becomes 
established  from  the  dryness  of  the  mouth.  Nausea  and  vomiting 
are  late  symptoms.  Frontal  headache  is  present  in  22  per  cent,  of 
cases  of  urinary  obstruction.  The  skin  is  dry  and  harsh,  and  these 
patients  seldom  sweat. 

The  complexion  is  sallow  and  muddy.  Emaciation  is  often 
present,  and  is  very  -marked  if  there  be  septic  inflammation  of 
the  kidneys.  Hiccough  is  a  sign  of  grave  import ;  it  may  be 
slight  and  gradually  increase,  exhausting  the  patient's  strength. 
Drowsiness  is  a  constant  and  grave  symptom  of  renal  failure. 
In  obstructive  anuria,  however,  the  mind  remains  clear  for  days. 
Restless  delirium  is  a  frequent  symptom,  and  is  most  marked  at 
night. 

The  temperature  is  not  raised  unless  septic  complications  are 
present.  In  cases  where  the  kidney  is  being  slowly  destroyed  by 
obstruction  the  temperature  is  slightly  subnormal,  and  in  ob- 
structive anuria  it  is  continuously  subnormal.  In  chronic  septic 
pyelonephritis  a  subnormal  temperature  is  present,  and  may  be 
interrupted  from  time  to  time  by  rises  of  temperature  from  exacer- 
bations of  the  disease.  In  acute  septic  pyelonephritis  and  during 
the  development  of  a  pyonephrosis  the  temperature  is  high  and 
swinging.  In  suppression  of  urine  following  urethral  operations 
the  temperature  rises  rapidly  after  a  rigor,  and  remains  high  during 
the  course  of  the  disease.  There  is  no  oedema,  nor  are  there 
changes  in  the  heart  and  vessels.  If  the  renal  failure  is  due  to 
septic  infection  there  may  be  rigidity  and  tenderness  over  one  or 
both  kidneys.  In  acute  septic  pyelonephritis  and  in  some  cases 
of  pyonephrosis  one  kidney  is  frequently  enlarged. 

2.  Examination  of  the  Urine 

The  average  specific  gravity  of  the  urine  varies  from  1018  to 
1020.  It  is  temporarily  decreased  by  copious  draughts  of  fluid, 
and  increased  by  any  condition  which  tends  to  reduce  the  watery 
contents  of  the  urine,  such  as  profuse  sweating  or  diarrhoea.  A 
continuously  low  specific  gravity  when  associated  with  other  signs 


12  THE   KIDNEY  [chap. 

of  disease  is  a  grave  symptom.  In  all  forms  of  polynria  except 
diabetes  mellitus  the  specific  gravity  is  lowered.  Thus,  in  hysterical 
polyuria  it  may  be  1005  or  less.  The  specific  gravity  is  estimated 
with  sufficient  accuracy  by  means  of  a  urinometer,  which  should 
float  free  in  the  urine.  The  figure  is  obtained  by  reading  off  the 
lowest  mark  that  can  be  seen  with  the  eye  at  the  level  of  the  fluid. 

The  average  quantity  of  urea  excreted  in  twenty-four  hours 
in  a  healthy  individual  is  about  33  grammes  (500  grains),  or  2 
per  cent.  The  excretion  of  urea  is  diminished  in  disease  of  the 
kidneys,  but  there  are  many  extrarenal  causes  for  variation  in 
the  quantity  of  urea  contained  in  the  urine,  such  as  diet,  absorp- 
tion, tissue  metabohsm,  and  hepatic  action. 

Urea  forms  only  about  80  per  cent,  of  the  total  nitrogen  com- 
pounds in  the  urine,  and  if  accurate  observations  are  to  be  made 
the  total  nitrogen  excretion  should  be  estimated. 

Temporary  variations  in  the  urea  output  are  valueless  in  esti- 
mating the  renal  function  unless  the  diet  and  other  factors  which 
influence  the  production  of  urea  are  carefully  controlled.  Con- 
tinuous reduction  in  the  urea  is  of  greater  value,  and  shows  that 
the  function  of  the  kidneys  is  seriously  impaired.  The  elimina- 
tion of  chlorides  in  the  urine  does  not  furnish  any  precise  informa- 
tion in  regard  to  the  activity  of  the  renal  function. 

Quality  of  Urine 

Polyuria. — The  quantity  of  urine  passed  in  twenty-four 
hours  amounts  to  40  to  50  oz.  (1,200  to  1,500  c.c).  Considerable 
variation  may  be  observed,  depending  upon  the  removal  of  water 
from  the  body  by  the  skin,  lungs,  intestines,  etc.,  the  amount  of 
fluid  ingested,  and  other  physiological  factors. 

Transient  polyuria  occurs  after  an  attack  of  fever  or  an  epilep- 
tic attack.  There  is  continuous  polyuria  in  the  diflerent  forms 
of  diabetes,  in  chronic  interstitial  nephritis,  whether  in  the  form 
of  chronic  Bright's  disease  or  the  result  of  back-pressure  in  urinary 
obstruction. 

Frequent  contraction  of  the  bladder  is  said  to  increase  the 
quantity  of  urine  secreted,  and  in  all  forms  of  disease  where  there 
is  increased  frequency  of  micturition  there  is,  as  a  rule,  an  increased 
quantity  of  urine. 

Polyuria  is  a  constant  symptom  in  the  chronic  interstitial 
nephritis  that  results  from  urinary  obstruction  (stricture,  enlarged 
prostate).  (Chart  1.)  The  polyuria  in  such  cases  is  a  grave  symp- 
tom of  permanent  reduction  of  the  renal  efficiency.  The  quantity 
excreted  varies  from  80  to  100  oz.  in  twenty-four  hours.  It  is 
liable  to  sudden  falls,  each  of  which  marks  a  temporary  reduc- 


n] 


POLYURIA 


13 


tion  in  the  already  enfeebled  renal  function.  The  percentage  of 
urea  and  other  urinary  constituents  is  much  reduced.  The  total 
quantity  of  these  bodies  passed  in  twenty-four  hours  may  be 
only  slightly  below  the  normal  standard,  but  may  be  much  smaller. 

Polyuria  is  observed  in 
cases  of  advanced  calcu- 
lous disease,  where  the 
kidney  tissue  has  been  re- 
duced to  a  mere  shell  and 
is  the  seat  of  chronic  inter- 
stitial nephritis  and  chronic 
septic  nephritis.  There  is 
polyuria  in  the  early  stage 
of  tuberculous  disease  of 
the  kidney,  due  to  conges- 
tion of  the  organ.  Tem- 
porary polyuria  usually  fol- 
lows the  removal  of  a 
diseased  kidney,  and  at 
the  same  time  the  specific 
gravity  is  raised  and  the 
quantity  of  urea  increased. 
(Chart  ^2.)  This  polyuria 
is  due  to  the  rehef  of  a 
reno-renal  depressant  reflex 
which  a  diseased  kidney 
exerts  upon  its  healthy  or 
less  diseased  neighbour. 

Polyuria  may  alternate 
with   oliguria   in    cases    of 
chronic       septic      pyelone- 
phritis.     In     this     disease 
there    is   polyuria    with    a 
subnormal  temperature  al- 
ternating with    attacks    of 
oliguria     with     a     rise     of 
temperature.    (Charts  3,  4.) 
Nervous  or  hysterical 
polyuria. — This  form    of    polyuria    occurs    in   young   adults,   in 
nervous,  excitable  individuals,   both   male    and   female.  •  It  may 
commence  suddenly  and  continue  for  a  few  hours  or  for  several 
weeks. 

The  patient  may  be  subject  to   attacks  of  this  nature  from 
time  to  time.     The  urine  is  pale,  clear,  and  of  low  specific  gravity. 


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THE   KIDNEY 


[chap. 


and  the  percentage  of  the  urinary  constituents  is  reduced.  No 
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In  a  prolonged  attack  the  urine  is  increased  by  one  or  two   pints 
in  the  twenty-four  hours.     Thirst  is  not  a  marked  feature  of  the 
malady.    There  are  usually  obscure  abdominal  pains  which  are  never 
severe  or  definitely  localized. 
Oliguria    and   anuria. 
— Oliguria  is  a  diminished 
secretion  of  urine  ;  anuria  is 
a  total  cessation  of  the  se- 
cretion. The  agencies  which 
bring    about    oliguria    and 
anuria  may  be  classified  in 
the  following  manner  : — 

(1)  Hysterical  anuria. 

(2)  Anuria       due      to 

changes  in  the 
general  circulation 
of  the  body. 

(3)  Reflex  anuria  : 
(a)  Urethra. 
(6)  Bladder, 
(c)  Ureter. 
{d)  Kidney. 

(4)  Infective  anuria  : 
(a)  Hsematogenous 

(i)  Toxic, 
(ii)  Bacterial. 
(6)  Ascending  urin- 
ary. 

(5)  Urinary-  tension 

anuria : 

1.  Obstruction — 

(a)  Gradual. 
(6)  Sudden. 

2.  Sudden  relief  of 
tension.  * 

(6)  Anuria    from     de- 

struction or  re- 
moval of  renal 
tissue : 

(«)  Gradual        de- 
struction. 
(6)  Sudden      com- 
plete     destruc- 
tion or  removal. 


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16 


THE  KIDNEY 


[chap. 


(1)  Hysterical  anuria. — There  may  b 
suppression  in  cases  of  severe  hysteria, 
several  hours,   or  even  for  some  days. 


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le  diminution  or  complete 
Anuria  has  lasted  for 
Apart  from  continuous 
vomiting,  no  symp- 
toms of  uraemia  have 
been  observed  in  such 
cases.  A  copious  poly- 
uria immediately  fol- 
lows the  anuria. 

(2)  C  i  r  c  u  I  atory 
anuria. — After  severe 
and  prolonged  opera- 
tions the  secretion  of 
urine  is  temporarily 
reduced  or  suspended. 
This  may  last  for 
several  hours,  and  is 
due  to  the  low  blood 
pressure  of  shock  and 
collapse.  The  effect 
of  the  anaesthetic,  and 
perhaps  the  absorption 
of  antiseptics,  may 
play  a  subordinate 
part.  Where  the  kid- 
neys are  diseased  and 
the  active  renal  tissue 
much  reduced  this  may 
be  the  exciting  cause 
of  continuous  and  fatal 
anuria.  Usually  the 
function  is  restored 
when  the  blood  pres- 
sure again  rises.  In 
shock  following  grave 
injuries  to  the  body,  in 
the  collapse  of  cholera, 
and  in  other  conditions 
of  extreme  lowering 
of  the  blood  pressure, 
anuria  is  present. 

(3)  Reflex  anuria. 
— The  passage  of  an 
instrument   along    the 


II]  ANURIA  17 

urethra  may  be  followed  by  suppression  of  urine.  In  such  a  case 
the  urethra  may  be  healthy,  or  it  may  be  the  seat  of  stricture  or 
other  disease.  In  some  cases  no  blood  follows  the  passage  of 
the  instrument,  and  post-mortem  examination  of  the  urethra 
fails  to  reveal  the  slightest  abrasion.  The  kidneys  are  sometimes 
the  seat  of  chronic  interstitial  nephritis  or  chronic  septic  nephritis, 
and  they  have  been  found  deeply  congested  ;  but  in  some  cases 
nothing  abnormal  has  been  discovered. 

Suppression  of  urine  is  more  likely  to  occur  when  an  instru- 
ment has  been  roughly  passed,  and  where  the  disease  for  which  it 
is  used  is  in  the  deeper  part  of  the  urethra.  In  the  majority  of 
cases  there  has  been  difficulty  in  passing  an  instrument,  and  this 
has  been  followed  by  some  bleeding.  Some  hours  later,  usually 
immediately  after  the  first  passage  of  urine,  the  patient  has  a 
rigor,  and  the  temperature  rises  to  103°  or  104°  F.,  after  which 
no  urine  is  secreted. 

The  majority  of  these  cases  are  due  to  septic  absorption. 
Some  are  apparently  due  to  a  combination  of  septic  absorption 
and  a  reflex  effect  on  the  circulation  of  the  kidneys,  while  a  few 
are  purely  reflex  in  nature. 

Surgical  interference  with  the  bladder  may  be  followed  by 
suppression  of  urine,  especially  if  the  kidneys  are  already  diseased. 

Reflex  impulses  from  a  ureter,  started  by  a  stone  or  the 
catheter,  may  inhibit  the  secretion  of  the  corresponding  kidney. 
The  function  of  the  second  kidney  may  be  inhibited,  and  com- 
plete anuria  result,  by  reflex  impulses  from  a  stone  in  the  ureter. 
The  corresponding  kidney  is  affected  partly  by  blocking  of  its 
ureter  and  partly  by  reflex  impulses  from  the  ureter.  The  second 
kidney  may  be  healthy  in  such  a  case,  but  almost  invariably  it  is 
impaired  by  disease. 

Sudden  kinking  of  the  ureter  by  torsion  of  the  pedicle  in  a 
case  of  movable  kidney  may  bring  about  a  temporary  diminution 
in  the  secretion,  or  a  complete  suppression.  The  function  is  re- 
established when  the  torsion  is  relieved. 

There  is  a  reflex  depressant  effect  exerted  by  one  diseased 
kidney  on  its  healthy  or  less  diseased  neighbour.  In  cases  of 
pyonephrosis,  unilateral  suppurative  pyelonephritis,  and  other 
irritative  conditions,  the  total  quantity  of  urine  is  usually  much 
reduced.  On  removal  of  the  diseased  kidney  the  activity  of  the 
remaining  kidney,  relieved  of  the  depressant  reflex,  is  greatly 
increased. 

Surgical  interference  with  one  kidney  is  said  to  produce  a 
reflex  inhibition  of  the  acti\dty  of  its  neighbour.  Although  it 
appears  probable  that  some  such  effect  may  be  temporarily 
c 


18  THE   KIDNEY  [chap. 

produced,  it  can  only  last  during  the  time  of  the  operation,  and 
if  the  second  kidney  is  adequate  before  the  operation  this  cause 
will  not  induce  postoperative  anuria.  Other  factors  which  are 
much  more  potent  in  producing  anuria  after  a  kidney  operation 
are  the  effect  of  the  anaesthetic  and  of  absorbed  antiseptics  on  the 
remaining  kidney  and  the  low  blood  pressure  of  shock.  Further, 
the  remaining  kidney  may  have  been  inadequate  before  the  opera- 
tion, and  the  removal  of  its  neighbour  only  makes  this  evident. 
Irritation  of  the  kidney  pedicle  by  a  drainage  tube  after  nephrec- 
tomy has  been  found  to  produce  reflex  anuria  (Israel). 

(4)  Infective  anuria,  {a)  Hcematogenous. — In  acute  nephritis 
caused  by  a  hsematogenous  infection  in  septicsemia,  influenza, 
pneumonia,  typhoid  fever,  and  in  auto-intoxication  from  gastro- 
intestinal infections,  suppression  of  urine  is  frequently  present 
and  may  be  fatal.  Anuria  following  urethral  operations  where 
the  kidneys  are  healthy  and  no  ascending  infection  has  occurred 
is  probably  toxic  in  nature  in  many  cases. 

(6)  Ascending. — An  acute  ascending  affection  of  the  kidneys 
from  the  bladder,  arising  from  an  old-standing  cystitis  or  induced 
by  means  of  septic  instruments,  may  cause  complete  and  rapidly 
fatal  anuria.  Chronic  septic  pyelonephritis  secondary  to  disease 
of  the  lower  urinary  organs  is  accompanied  by  oliguria,  which 
becomes  more  pronoimced  with  acute  exacerbations  of  the  disease. 
and  complete  anuria  may  supervene. 

(5)  Urinary-tension  anuria. — {a)  Gradually  increasing  ob- 
struction to  the  outflow  of  urine,  such  as  is  met  with  in  enlarged 
prostate,  produces  a  slight  dilatation  of  the  kidney  and  chronic 
interstitial  nephritis,  and  in  this  way  the  secreting  tissue  of  the 
kidney  is  slowly  destroyed.  The  onset  of  anuria  in  these  cases 
is  referred  to  under  the  heading  of  Anuria  from  Destruction  of 
Eenal  Tissue  {see  below). 

(6)  Rapid  occlusion  of  both  ureters  is  met  with  in  malignant 
growths  of  the  bladder  involving  both  ureteric  orifices,  and  in 
other  pelvic  growths  such  as  carcinoma  of  the  uterus.  Where  a 
calculus  suddenly  blocks  the  lumen  of  the  ureter  of  ,  a  solitary 
kidney,  or  where  both  ureters  become  simultaneously  blocked, 
obstructive  anuria  results.  The  calculous  anuria  is  partly  obstruc- 
tive and  partly  reflex. 

(c)  Anuria  may  follow  the  sudden  relief  of  urinary  hyper- 
tension. When  the  urine  has  been  secreted  under  increased 
tension  for  some  time,  as  in  enlarged  prostate,  and  the  kidneys 
are  the  seat  of  interstitial  changes,  the  sudden  emptying  of  an 
over-distended  bladder  is  frequently  followed  by  suppression  of 
urine.     This  suppression  is  probably  due  to  sudden  engorgement 


11] 


ANURIA:   TREATMENT 


10 


of  the  renal  vessels.     It  is  more  likelv  to  occur  in   old  than  in 
young  men. 

(6)  Anuria  from   destruction   or    removal   of   renal   tissue. 

— The  removal  of  a  solitary  kidney,  or  a  working  kidney  whose 
neighbour  is  destroyed  by  disease,  is  followed  by  anuria  and  death 
in  a  few  days.  When  nephrectomy  has  been  performed,  and  the 
second  kidney  is  active,  but  incompetent  from  disease  to  perform 
the  total  renal  function,  the  patient  may  survive  the  operation 
and  gradually  sink  Avith  symptoms  of  increasing  renal  failure, 
and  die  some  months  after  the 
operation.  Where  disease,  such 
as  stricture,  enlarged  prostate,  or 
calculus  or  tuberculosis  of  the 
kidney,  has  gradually  destroyed 
the  tissue  of  the  kidney,  there  is 
usually  polyuria.  This  is  inter- 
rupted from  time  to  time  by 
attacks  of  oliguria  or  anuria 
brought  on  by  shght  causes. 
(Chart  5.)  Finally  an  attack  of 
anuria  proves  fatal. 

Treatment  of  anuria. — The 
follomng  measures  should  be 
adopted  in  cases  of  anuria  :  Di- 
uretics are  administered,  such 
as  caffeine  (5  gr.),  diuretin  (10 
gr.),  theocin  sodium  acetate  (5 
gr.),  hot  Contrexeville  water,  and 
citrate  of  potash  (25  gr.). 

Hot  fomentations  and  poul- 
tices are  applied  over  the  loins. 

The  patient  is  placed  in  a 
hot  pack  or  a  vapour  bath. 

A   saline  infusion    of    several 


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Chart  5. — Urine  and  tempera- 
ture in  obstructive  anuria, 
showing  subnormal  tempera- 
ture and  practically  com- 
plete anuria,  interrupted  by 
a  copious  polyuria. 


pints  (sodium  chloride,  1  dr.  to  the  pint)  is  slowly  introduced  into 
the  rectum. 

In  severe  cases  the  introduction  of  one  to  two  pints  or  more  of 
saline  solution  into  a  vein  has  a  powerful  diuretic  effect.  It  has 
recently  been  pointed  out  that  the  kidneys  are  embarrassed  by 
the  introduction  of  chlorides,  and  these  should  be  replaced  by 
sugar  solutions,  which  are  powerfully  diuretic. 

In  urgent  cases  a  pint  of  glucose  solution  (25  per  cent.)  is 
infused  into  a  vein.  This  solution  is  hypertonic,  and  increases  the 
molecular  content  of  the  blood. 


20 


THE   KIDNEY 


[chap. 


Ill  less  urgent  cases  the  injection  may  be  given  subcutaneously 
or  intramuscularly.  Jeanbrau  recommends  an  isotonic  solution 
of  glucose  (47  grm.  per  1,000),  or  of  saccharose  or  lactose  (90  grm. 
per  1,000). 

A  solution  of  5  per  cent,  of  glucose  is  isotonic,  and  I  use  this 
in  preference  to  saline  solution  in  anuria. 

Nephrotomy  is  followed  by  re-estab- 
lishment of  the  secretion  in  some  ap- 
parently desperate  cases.  This  will  be 
discussed  in  connection  with  the  dis- 
eases causing  anuria. 

Hysterical  anuria  is  treated  by 
bromides,  valerian,  etc.  Diuretics  should 
be  administered,  and  care  exercised  that 
the  patient  has  no  opportunity  of  fraudu- 
lently disposing  of  urine  that  may  be 
passed. 

In  circulatory  anuria  the  treatment 
is  directed  to  raising  the  blood  pressure 
by  means  of  strychnine,  ergot,  adrena- 
lin, and  pituitary  extract,  and  by  saline 
infusion. 

In  reflex  anuria  the  cause  of  the 
reflex  inhibition  should  be  removed  {see 
Calculous  Anuria,  p.  279,  and  Pyelone- 
phritis, p.  127). 

In  infective  anuria  it  may  be  neces- 
sary to  incise  one  or  even  both  kidneys 
(see  Pyelonephritis,  p.  135). 

Sudden  r.elief  of  long-established  se- 
vere obstruction— as,  for  example,  the 
complete  emptying  of  a  chronically  over- 
distended  bladder  in  a  case  of  enlarged 
prostate — should  be  avoided. 


Fig.  9. — Beckmann's  ap- 
paratus for  estimating 
the  freezing-point  of 
the  urine. 


A,  Glass  jar ;  B,  stirring  rod  ;  C, 
outer  glass  tube  ;  D,  inner  glass 
tube  for  urine  ;  E,  platinum  stirring 
rod  ;  F,  Beckmann's  thermometer. 


3.  Tests  of  the  Renal  Function 

(1)  Cryoscopy.^ — For  details  of  the 
method  of  cryoscopy  of  the  urine  and  blood  the  reader  is  referred 
to  special  works  dealing  with  this  subject.^ 

By  estimating  the  freezing-point  (Fig.  9)  the  molecular  con- 
centration of  a  fluid  is  ascertained,  and  as  the  molecular  concen- 
tration is  proportional  to  the  osmotic  pressure  the  latter  may  thus 

^Thomson  Walker,  "The  Estimation  of  the  Renal  Function  in  Urinary 
Surgery."     1908, 


II]  CRYOSCOPY  21 

be  measured.  The  osmotic  piessure  of  tlic  mine  is  constantly 
higher  than  that  of  the  blood,  and  the  work  of  extracting  this 
fluid  of  greater  osmotic  pressure  from  one  of  lower  osmotic  pres- 
sure is  performed  by  the  kidney.  If  these  organs  are  diseased 
their  power  of  bringing  about  a  change  in  the  osmotic  pressure 
of  the  fluid  passing  through  is  reduced.  The  osmotic  pressure 
therefore  falls,  and  approaches  more  nearly  that  of  the  blood. 

When  the  kidneys  are  diseased  the  molecular  content  of  the 
urine  is  reduced,  and  the  freezing-point  of  the  urine  is  raised. 
The  freezing-point  of  the  urine  is  indicated  by  the  sign  A)  o^)  to 
avoid  confusion  with  other  fluids,  A  U  may  be  used.  In  the 
healthy  state  this  is  liable  to  considerable  variations.  It  is  usually 
between  —1-30°  and  —2-20°  C,  but  after  copious  libations  it 
may  rise  to  —1°  C,  and  when  the  urine  is  concentrated  by  profuse 
sweating  the  figure  may  be  —2-30°  C,  or  lower.  In  nervous 
polyuria  the  point  may  be  reduced  to  —0-46°  or  —0-17°  C. 

A  fallacy  is  introduced  by  the  precipitation  of  urates  in  many 
urines  when  the  temperature  is  lowered. 

The  variations  in  the  point  A  U  are  so  considerable  in  healthy 
individuals  that  cryoscopy  of  the  urine  alone  has  little  value  as 
an  indication  of  the  renal  function. 

Cryoscopy  of  the  blood. — The  freezing-point  of  the  blood 
is  remarkably  constant  at  —0-56°  C,  and  the  point  A  of  the 
serum  is  practically  the  same  as  that  of  the  blood.  Where  one 
kidney  is  inefficient  no  change  is  found  in  the  point  /\,  but  when 
the  Eimction  of  both  kidneys  is  reduced  the  point  A  is  lowered. 
A  point  A  of  —0-57°  or  —0-58°  C.  indicates  a  reduction  in  the 
total  renal  function,  and  a  point  A  of  —0-60°  C.  is  a  contra- 
indication to  nephrectomy.  Lowering  of  the  point  A  to  —0-60°  C. 
or  under  may  be  observed  apart  from  disease  of  the  kidney  in 
cardiac  and  respiratory  affections,  and  in  diabetes,  epilepsy,  and 
other  conditions.  Further,  the  normal  point  A  of  the  blood  does 
not  prove  that  the  kidneys  are  efficient,  for  the  blood  may  have 
been  hydrsemic  and  the  point  A  raised,  and  the  renal  lesion  only 
succeeds  in  reducing  the  point  A  to  normal.  This  method  is  not 
always  trustworthy,  although  it  may  give  useful  information 
when  it  is  impossible  to  separate  the  urines  of  the  two  kidneys 
for  examination. 

Comparative  cryoscopy  of  the  urine  and  the  blood. — The 
freezing-point  of  the  normal  urine  is  —1-5°  to  —2°  C,  and  that 
of  the  blood  serum  —0-56°  C.  The  quotient  of  these  will  be  2-3° 
to  3-5°  C,  and  when  this  figure  diminishes  we  may  conclude  that 
there  is  a  diminution  in  the  permeability  of  the  kidney.  There 
is,  however,  too  wide  a  range  of  variation  in  the  freezing-point 


22 


THE   KIDNEY 


[chap. 


of  the  urine  in  the  normal  individual  for  reliable  information  to 
be  obtained  by  this  means.  If  the  volume  of  the  urine  be  taken 
into  account,  this  fallacy  will  be  corrected.  Thus  the  quotient 
is  multiplied  by  the  number  of  c.c.  of  urine  secreted  in  twenty- 
four  hours.  The  figures  thus  obtained  vary  in  healthy  individuals 
from  3,000  to  5,000.  The  remarkable  tendency  of  the  blood  to 
remain  at  a  constant  molecular  concentration  under  any  condi- 
tion reduces  the  value  of  this  test. 

Cryoscopy  of  the  urine  and  estinnation  of  the  chlorides. 
— Koranyi  believes  that  the  glomeruli  of  the  kidney  filter  through 
a  solution  of  sodium  chloride  from  the  blood,  and  as  this  passes 
down  the  tubules  water  is  absorbed  and  molecules  of  sodium 
chloride  are  removed,  and  replaced  by  molecules  of  urea,  uric  acid, 
etc.,  from  the  blood.    He  therefore  proposes  to  estimate  the  renal 


Fig.  10. — Apparatus  for  measuring  the  electrical 
conductivity  of  urine. 

A,  Induction  coil ;  B,  vessel  containing  fluid  ;  C,  rheostat ;  D,  movable  contact ;  E,  telephone. 

function  by  noting  the  relation  between  the  point  A  U  (the  total 
molecular  content)  and  the  sodium  chloride  content  in    100  c.c. 

of  urine.     This  is  expressed  by  the  formula  ^ry— pi-     In  the  normal 

state  this  does  not  exceed  1-7.  The  result  depends,  however,  not 
upon  the  permeability  of  the  kidney,  but  upon  the  rapidity  of 
secretion,  which  affects  the  time  allowed  for  interchange  of  the 
sodium  chloride  molecules.  This  again  depends  upon  the  rate 
of  circulation  through  the  kidney.  In  order  to  overcome  such 
fallacies  the  formula  has  been  corrected  by  adding  to  it  the  volume 
of  urine  in  cubic  centimetres  for  twenty-four  hours  and  the  total 
body-weight  in  kilogrammes.  The  formula  becomes  so  compli- 
cated that  the  figures  obtained  are  of  very  doubtful  value. 

Wright  and  Kilner  have  suggested  a  method  by  which  the 
molecular  content  of  the  blood  is  measured  by  means  of  dilution 


Ill  METHYLENE-BLUH  TEST  23 

with  a  staiulai'd  solution  of  sodium  chloride.  At  a  certain  point 
of  dilution  destruction  of  the  red  blood-corpuscles  (htemolysis) 
takes  place,  and  the  amount  of  dilution  required  to  produce  this  is 
an  index  of  the  molecular  concentration  of  the  blood. 

Estimation  of  the  electrical  conductivity  of  the  urine  has  been 
used  to  estimate  the  molecular  content,  and  the  figure  compared 
with  that  of  salt  solution.  (Fig.  10.)  Further,  the  electrical  resist- 
ance of  the  urine  has  been  compared  with  that  of  the  blood  and 
a  haemo-renal  index  obtained  ;  but  neither  this  method  nor  the 
estimation  of  the  surface  tension  of  the  urine,  which  has  also  been 
used,  has  been  widely  adopted. 

It  may  be  said  of  all  these  methods  of  estimation  of  the  mo- 
lecular content  of  the  urine,  that  the  delicacy  of  the  instruments 
required  and  the  skill  necessary  for  their  observation  preclude 
them  from  general  chnical  use,  and  that  the  results  they  have 
given  could  equally  well  and  much  more  easily  be  obtained  by 
testing  the  specific  gravity  by  means  of  the  ureometer. 

(2)  Methylene-blue  test. — The  methylene  blue  should  be 
pure  and  free  from  arsenic,  and  must  dissolve  completely  in 
water.  Methylene  blue  is  absorbed  from  the  intestine  or  from 
an  intramuscular  injection  into  the  blood,  and  excreted  by  the 
kidney,  and  to  a  less  extent  by  the  liver.  Some  of  the  latter  is 
reabsorbed  from  the  intestine.  The  blue  cannot  be  recognized  in 
the  blood.  It  appears  in  the  urine  partly  as  blue  and  partly  in 
the  form  of  a  chromogen  or  colourless  body  which  is  transformed 
into  blue  by  boiling  with  acetic  acid. 

After  cleansing  the  skin,  15  minims  of  a  5  per  cent,  aqueous 
solution  are  slowly  injected  into  the  muscles  of  the  buttock. 
Chromogen  appears  in  the  urine  in  from  fifteen  to  twenty  minutes, 
and  a  trace  of  blue  is  detected  half  an  hour  after  the  injection. 
The  urine  rapidly  becomes  olive  green  and  then  emerald  green 
bluish  green,  prussian  blue,  and  finally  a  deep  blue  colour.  The 
colour  may  not,  however,  pass  beyond  emerald  green.  During  the 
first  four  or  five  hours  of  the  elimination  chromogen  is  present  in 
greater  quantity  than  blue,  and  may  be  detected  by  extracting 
the  blue  with  chloroform  and  then  boihng  the  cleared  urine  with 
acetic  acid.  (Chart  6.)  The  excretion  of  blue  is  at  its  height  in 
four  or  five  hours,  remains  stationary  for  several  hours,  and  then 
gradually  decHnes.  In  from  forty  to  sixty  hours  it  has  usually 
disappeared.  The  chromogen  disappears  from  the  urine  some 
hours  before  the  methylene  blue.  In  pathological  conditions  of  the 
kidney,  such  as  chronic  interstitial  nephritis,  tuberculous  kidney, 
or  hydronephrosis  (Charts  7,  8),  the  appearance  of  methylene  blue 
is  delayed  for  one,  two,  or  more  hours.     An  early  onset  and  rapid 


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CllAI'.    II 


INDIGO-CARMINE  TEST 


eliiuinutioii  liavc  been  obscrvctl  in  pareischyinatous  nephritis.  In 
surgical  disease  of  the  kidneys  elimination  of  blue  may  be  pro- 
longed for  several  days.  I  have  observed  the  excretion  during 
a  period  of  eight  days  and  seventeen  hours  in  a  man  of  67 
y^ars  who  suffered  from  eidarged  prostate  and  interstitial  changes 
in  the  kidneys.  After  the  first  twenty-four  hours  only  traces  of 
blue  are  passed  in  such  cases,  and  the  total  quantity  of  blue 
eliminated  is  usually  much  reduced.  The  quantity  of  blue  may 
bo  estimated  bv  a  colorimetric  method,  but  it  is  usually  sufficient 


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Chart  7. — Elimination  of  methylene  blue  (continuous  line)  in 
tuberculous  kidney.  Delayed  commencement  and  rapid 
short  elimination. 

to  note  the  varying  depth  of  colour,  and  from  this  to  judge  of  the 
quantity  eliminated. 

Intermittent  elimination  may  occur,  and  is  said  to  result  from 
an  inhibitory  action  on  the  kidney  of  bodies  produced  in  the 
liver  in  hepatic  disease,  but  I  have  observed  it  in  the  healthy. 

(3)  Indigo -carmine  test, — An  injection  of  20  c.c.  of  0-4 
per  cent,  solution  of  indigo  carmine  is  made  into  the  muscles 
of  the  buttock.  The  urine  becomes  tinged  in  five  minutes,  the 
excretion  reaches  its  highest  point  in  half  to  three-quarters  of  an 
hour,  and  then  falls  gradually  and  disappears  in  about  twelve 
hours.  Delay  in  the  commencement  and  a  diminution  in  the 
quantity  of   dye   eliminated   are  indications   of   a   reduced  renal 


26 


THE   KIDNEY 


[chap. 


function.  The  quantity  of  fluid  which  must  be  injected  is  a 
drawback  to  this  method.  The  solubihty  of  indigo  carmine  does 
not  permit  of  more  concentrated  solution  being  used. 


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Rosaniline,  iodide  of  potassium,  and  salicylic  acid  have  been 
tried  as  tests  of  the  renal  function,  but  have  not  been  found 
satisfactory. 


iij  TESTS   OF   RENAL  FUNCTION  27 

(4)  Phenol-sulphone-phthalein  test.'  A  cubic  ceiitinietic 
of  a  solution  coutaiuiut!;  <>  ui<i;.  of  phciiol-sulphoue-phthaleiu 
is  injected  subcutaneouslv  in  the  ujiper  arm,  and  the  urine 
is  collected.  The  urine  is  rendered  alkaline  by  the  addition 
of  sodium  hydrate  (25  per  cent.),  and  assumes  a  brilliant  purple- 
red  colour.  The  sample  of  urine  is  diluted  to  1  litre  with  dis- 
tilled water  and  compared  in  a  Duboscq's  calorimeter  with  a 
standard  solution  (|-  c.c.  of  the  injection  fluid  in  a  litre  of  water 
rendered  alkaline  by  the  addition  of  NaOH).  In  normal  cases 
the  colouring  material  appears  in  from  five  to  ten  minutes ;  40 
to  60  per  cent,  of  the  drug  is  excreted  in  the  first  hour,  20  to  25 
per  cent,  in  the  second  hoiir,  and  60  to  85  per  cent,  in  two  hours. 
The  presence  of  blood  in  the  urine  introduces  a  fallacy,  and  renders 
the  test  more  difficult  even  after  filtering  the  urine. 

This  test  is  at  present  under  trial. 

(5)  Toxicity -of -urine  test.— The  normal  urine  is  highly 
poisonous,  but  the  exact  nature  of  the  poison  is  imknown. 
The  injection  of  a  certain  quantity  of  urine  into  a  rabbit  causes 
symptoms  of  poisoning,  and  after  a  varying  interval  the  animal 
dies.  For  rabbits  the  lethal  dose  is  stated  at  40  to  50  grm.  per 
kilo  of  body  weight.  Variations  in  this  dose  are  stated  to  be 
due  to  the  accumulation  of  poisons  in  the  body  from  which  the 
urine  was  derived,  or,  on  the  other  hand,  increased  elimination  of 
poisons  in  the  urine.  The  urine  has  been  injected  into  the  veins, 
the  serous  cavities,  the  cellular  tissues,  and  intracerebral  injec- 
tions have  been  used.  Most  observers  who  have  used  the  method 
are  agreed  that  so  long  as  the  figures  are  not  considered  to  be 
mathematically  exact  the  estimation  of  the  toxicity  of  the  urine 
will  afford  useful  information.  By  a  comparison  of  the  toxic 
properties  of  the  urine  and  the  blood  in  renal  disease  more  exact 
data  may  be  obtained,  but  even  here  there  is  some  degree  of 
fallacy,  for  the  toxicity  of  the  blood  tends  to  remain  constant, 
accumulated  poisons  being  stored  in  the  tissues. 

(6)  Phloridzin  test. — When  phloridzin  is  administered  by  the 
mouth  or  subcutaneously  a  temporary  glycosuria  follows.  The 
production  of  sugar  has  been  shown  to  take  place  in  the  kidney. 
The  quantity  of  sugar  excreted  does  not  depend  upon  the  dose  of 
phloridzin,  provided  sufficient  is  given  to  produce  the  maximal 
effect.  A  second  injection  of  phloridzin  given  shortly  after  the 
first  will  produce  a  greater  quantity  of  sugar  proportionally  than 
the  first  injection. 

The  source  of  the  sugar  is  apparently  the  tissue  protein,  and 

^  Geraghty,  Trans.  Amer.  Assoc.  Genito-Urinary  Surgeons,  vol.  v.,  1910 


28 


THE  KIDNEY 


[chap.  II 


the  phloridzin  influences  the  kidney  so  that  it  manufactures  sugar 
from  this  body. 

A  subcutaneous  injection  of  10  mg.  of  phloridzin  is  given. 
Sugar  can  usually  be  detected  in  the  urine  in  a  healthy  individual 
in  fifteen  minutes,  occasionally  after  thirty  minutes.  The  glyco- 
suria is  at  its  height  from  three-quarters  to  one  hour  after  the 
injection,  and  has  usually  ceased  in  two  to  two  and  a  half  hours. 
An  injection  of  10  mg.  of  phloridzin  will  normally  produce  from 

1  to  2  grm.  of  glucose.     Cer- 
sTRicTURE.  tain  drugs  reduce  the  secre- 

tion of  sugar ;  among  these 
are  glycerine,  salicylate  of 
soda,  antipyrin,  and  piperazin. 
Delay  in  the  appearance 
of  sugar  in  the  urine  indi- 
cates an  interference  with  the 
renal  function.  A  prolonged 
duration  of  glycosuria,  espe- 
cially if  it  coincides  with  a 
total  reduction  in  quantity, 
points  to  a  lowered  renal 
activity.  The  lowest  limit  of 
normal  glycosuria  lies  be- 
tween 50  eg.  and  1  grm.,  and 
the  highest  between  2  and 
2-50  grm.  Occasionally  a 
diminished  production  of 
sugar  (hypoglycosuria)  or  an 
increased  production  (hyper- 
glycosuria)  may  be  observed 
in  diseases  which  do  not 
directly  affect  the  kidneys, 
and  even  in  normal  indi- 
viduals, but  this  is  exceptional.  In  almost  all  cases  of  renal 
disease,  when  the  lesion  is  bilateral  there  is  some  variation  in 
the  phloridzin  glycosuria.  Usually  this  takes  the  form  of  diminu- 
tion' of  the  quantity  eliminated.  Sometimes  there  is  complete 
absence  of  sugar. 

In  urinary  obstruction  (stricture,  enlarged  prostate)  there  is 
diminished  elimination  of  sugar.  (Charts  9,  10.)  When  the  kidneys 
are  damaged,  and  when  pronounced  renal  complications  are  pre- 
sent, sugar  may  be  absent.  In  primary  surgical  diseases  of  the 
kidneys  the  sugar  may  be  diminished  or  absent.  (Charts  11,  12.) 
A  diminished  phloridzin  glycosuria  indicates  a  depressed  renal 


HOURS 

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Chart  9. — Stricture  of  the  urethra. 
Delayed,  shortened,  reduced 
elimination  of  sugar. 


ENLARGED    PROSTATE. 


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SUGAR  % 

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Chart  10. — Prolonged  diminished  phloridzin  glycosuria  <5) 
in  enlarged  prostate. 


/^IGHT  KIDNEY 


LEFT  KIDNEYiDI5EASEDJ 


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Chart  11. — Calculous  hydronephrosis.     Traces  of  sugar 
on  diseased  side. 


29 


30 


THE   KIDNEY 


[chap.  II 


function  which  is  usually  due  to  disease  of  the  kidney,  and  com- 
plete absence  of  sugar  should  be  regarded  as  a  sign  of  advanced 
renal  disease. 

Compared  with  the  urea  output  and  the  general  symptoms  of 
renal  inadequacy,  the  phloridzin  test  is  more  delicate.     The  fallacy 


RIGHT    KIDNEY.  iPYONEPHROSIS 

LEFT     KIDNEY. 

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TOTAL  SUGAR 
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TOTAL  SUGAR 
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trace 

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(race 

Chart  12. — Calculous  pyonephrosis.     Diminished   elimination 
of  sugar  on  diseased  side. 

to  which  it  is  especially  liable  is  the  pronounced  effect  which  minor 
renal  changes  may  produce  upon  the  glycosuria.  The  test,  which 
we  owe  to  Casper,  is  especially  useful  for  unilateral  renal  disease, 
and  is  used  with  catheterization  of  the  ureters,  each  kidney  being 
drained  for  two  and  a  half  hours. 


CHAPTER  III 
EXAMINATION  OF  THE  KIDNEYS 

I.    INSPECTION  AND  PALPATION 

Inspection. — A  kidney  which  has  attained  a  large  size  becomes 
prominent  on  the  surface  of  the  abdomen.  The  prominence  is 
more  readily  seen  in  the  recumbent  than  in  the  erect  posture. 
There  is  usually  well-niarked  fullness  in  the  flank  on  the  affected 


Fig.   11. — Bilateral  hydronephrosis. 

The  left  kidney  is  distended  ;  the  right  has  been  the'subject  of  a  plastic  operation. 

side,  but  the  greatest  prominence  is  on  the  anterior  surface  of 
the  abdomen  (Fig.  11). 

With  the  patient  lying  on  the  back,  a  large,  rounded  swelling 
will  be  seen  to  one  side,  or  a  little  above  the  level,  of  the  umbiUcus. 
If  the  abdominal  wall  is  thick  and  the  tumour  very  large,'  only  a 
general  fullness  of  one  side  of  the  abdomen  is  apparent.     In  some 

31 


32 


THE   KIDNEY 


[chap. 


cases  of  hydronephrosis  the  pelvis  of  the  kidney  is  greatly  distended 
with  fluid,  while  the  kidney  itself  is  less  prominent.  A  vertical 
groove  will  frequently  be  observed  on  the  swelling,  and  indicates 
the  division  between  pelvis  and  kidney. 

Palpation. — The  patient  lies  on  his  back  on  a  high  couch, 
the  abdomen  fully  exposed,  the  shoulders  raised  on  a  pillow,  and 
the  knees  flexed,  with  the  feet  planted  on  the  table.  I  usually 
dispense  with  the  flexion  of  the  knees,  or,  at  most,,  place  a  pillow 
beneath  them.  The  surgeon  either  sits  on  the  edge  of  the  couch, 
or  stands  alongside  it,  about  the  level  of  the  patient's  pelvis  on 
the  side  to  be  examined.  To  examine  the  right  kidney,  he  places 
the  finger-tips  of  the  left  hand  beneath  the  patient's  loin  and  presses 
gently  upwards  in  the  angle  formed  by  the  last  rib  with  the  erector 


Fig.  12. — Palpation  of  right  kidney,  with  patient  recumbent 
and  thigh  extended. 

spinse  mass  of  muscles.  The  right  hand,  well  warmed,  is  placed 
flat  upon  the  surface  of  the  abdomen,  with  the  tips  of  the  fingers 
a  little  above  the  level  of  the  umbilicus  and  about  midway  between 
this  and  the  margin  of  the  ribs  (Fig.  12).  With  the  knees  fully 
flexed  the  axis  of  the  surgeon's  hand  lies  almost  transverse  (Fig.  13). 
With  the  knees  slightly  flexed  or  fully  extended  the  hand  can  be 
placed  with  its  long  axis  in  the  long  axis  of  the  patient's  body — a 
position  more  favourable  for  palpation  of  the  kidney.  The  patient 
is  directed  to  take  deep  inspirations,  but  not  to  force  expiration. 
As  the  abdomen  recedes  at  each  expiration  the  fingers  sink  in, 
and  the  deeper  position  is  maintained  during  the  next  inspiration, 
and  at  each  succeeding  expiration  the  fingers  sink  deeper.  There 
should  be  no  plunging  with  the  tips  of  the  fingers.  When  the  fingers 
have  sunk  deeply,  the  posterior  hand  should  try  to  raise  the  kidney 
at  each  inspiration.     To  examine  the  left  kidney,  the  position  of 


Ill] 


RENAL  PALPATION 


33 


the  surgeon  and  his  hands  are  changed  to  the  (;ther  side  of  the 
patient,  the  left  hand  being  used  for  the  front  of  the  abdomen  and 
the  right  hand  being  behind. 


Fig.   13. — Palpation  of  right  kidney :    dorsal  position  with  knee 
flexed.     Note  interlocking  of  thumbs. 

The  patient  may  also  be  examined  lying  upon  the  side  with 
the  knees  flexed.  The  uppermost  loin  is  palpated,  the  surgeon 
standing  behind  the  patient  (Fig.  14). 


Fig.  14. — Palpation  of  kidney  with  patient  lying  on  sound  side. 

In  thin  patients  and  in  children  the  whole  loin  may  be  grasped 
just  below  the  last  rib  by  placing  the  hand  behind  and  the  thumb 


34 


THE   KIDNEY 


[chap. 


in  front.  Additional  pressure  may  be  applied  to  assist  the  sinking- 
in  of  the  thumb  by  pressing  upon  it  with  the  fingers  of  the  other 
hand. 

The  same  method  may  be  practised  with  the  patient  standing 


Fig.  15.— Palpation  of  kidney  in  erect  posture. 

(Fig.  15),  but  it  is  more  difficult  to  get  relaxation  of  the  abdominal 
muscles  in  this  position. 

By  palpation  the  size,   outhne,   shape,  and  movements  of  an 
CDlarged  or  otherwise  abnormal  kidney  will  be  ascertained.     The 


Ill]  SIGNS   OF   RENAL   TUMOUR  35 

difficulties  in  examining  a  renal  tumour  are  stoutness  of  the  patient 
and  rigidity  due  to  contraction  of  the  abdominal  muscles.  Con- 
traction of  the  muscles  may  be  caused  by  pain  and  tenderness  of 
the  kidney,  or  by  rough  handling  or  the  application  of  a  cold  hand, 
or  by  nervousness  on  the  part  of  the  patient.  A  general  anaesthetic 
may  be  necessary  to  overcome  this. 

Signs  of  renal  tumour. — The  following  are  the  characteristic 
signs  of  an  abdominal  tumour  formed  by  the  kidney  (tumours 
caused  by  movable  kidneys  will  be  specially  described  under  that 
heading)  :  The  borders  of  the  kidney  are  all  rounded ;  there  are 
no  sharp  edges.  The  reniform  shape  can  frequently  be  distin- 
guished. Kidney  tumours  project  forwards  into  the  abdomen, 
and  although  the  depression  of  the  loin  may  be  obliterated,  there 
is  no  projection  of  a  definite  tumour  laterally  or  backwards.  The 
tumour  passes  backwards  into  the  kidney  area  at  the  angle  formed 
by  the  ribs  with  the  spinal  muscles,  and  the  fingers  pressed  in 
here  do  not  sink  in  behind  the  tumour.  With  the  fingers  in  this 
position  and  the  other  hand  on  the  front  of  the  abdomen,  the 
kidney  tumour,  if  a  small  one,  can  be  projected  against  the  anterior 
hand  by  a  sudden  push,  and  gives  a  characteristic  sensation,  called 
by  French  surgeons  "  ballottement."  When  the  tumour  is  a  large 
one,  and  already  in  contact  with  the  abdominal  wall  in  front,  the 
hands  in  these  positions  can  so  grasp  the  tumour  as  to  move  it 
backwards  and  forwards  between  them.  Renal  tumours  descend 
with  inspiration  unless  they  are  fixed  by  adhesions.  They  move 
rather  less  freely  with  respiration  than  tumours  of  the  spleen,  liver, 
or  suprarenal  body.  Unless  the  renal  tumour  is  very  large  it  does 
not  reach  the  middle  line,  but  it  may,  when  of  exceptional  size, 
cross  the  middle  line,  and  even  fill  the  whole  abdominal  area. 
When  of  moderate  dimensions  it  can  usually  be  separated  from  the 
liver.  The  edge  of  the  liver  may  sometimes  be  felt  on  the  surface 
of  the  enlarged  kidney.  Renal  tumours  rarely  extend  into  the 
iliac  fossa.  A  renal  tumour  due  to  a  large  growth  is  usually  tense 
and  elastic  to  the  touch.  Sometimes  the  tumour  is  hard  and 
nodular,  or  the  consistence  may  vary  in  different  parts,  being  soft 
and  fluctuating  at  one  part  and  hard  at  another.  Kidneys  dis- 
tended wdth  fluid  are  tense  and  elastic.  It  is  seldom  possible  to 
detect  fluctuation  in  these  tumours.  Occasionally  large  masses  of 
calculi  may  be  felt  in  the  kidney  as  very  hard,  irregular  nodules. 
The  colon  can  often  be  felt  crossing  the  tumour  vertically.  On 
percussion  the  tumour  is  dull,  and  the  dull  note  merges  into  that 
of  the  spinal  muscles  behind.  Anteriorly  there  is  a  zone  of  com- 
parative resonance  when  the  colon  is  pressed  forwards  in  front 
of  the  tumour ;  or  if  the  colon  is  collapsed,  and  dull  on  percussion, 


36  THE   KIDNEY  [chap. 

it  can  be  rolled  beneath  the  fingers.  An  enlarged  right  kidney 
may  push  the  ascending  colon  downwards  and  inwards.  On  the 
right  side  percussion  will  usually  show  an  area  of  resonance  between 
the  renal  dullness  and  that  of  the  liver,  which  can  be  demonstrated 
when  the  patient  is  standing. 

Differential  diagnosis  of  renal  tumour. — Tumours  of  the 
kidney  may  be  confused  with  enlargements  of  the  liver  or  spleen, 
ovarian  tumours,  suprarenal  tumours,  malignant  growths  of  the 
large  intestine,  and  perinephritic  tumours  and  inflariimations.  (1) 
An  enlarged  liver  has  no  intestine  in  front  of  it,  and  does  not  give 
the  sensation  of  ballottement.  The  outline  of  the  dullness  may 
be  characteristic,  and  the  sharp  lower  edge  may  be  felt,  or  there 
is  an  absence  of  roundness  at  the  edge.  Jaundice  and  biliary 
colic,  when  present,  point  to  disease  of  the  liver  and  gall-bladder, 
while  urinary  symptoms  may  give  the  clue  to  urinary  disease. 
A  floating  lobe  of  the  liver  may  be  confused  with  a  movable  kidney. 
In  all  cases  where  there  is  difficulty  in  diagnosis,  pyelography  gives 
invaluable  information  in  regard  to  the  position  of  the  kidney  and 
the  presence  of  dilatation  of  the  organ  (p.  42).  (2)  The  S'pleen 
has  no  bowel  in  front,  and  is  therefore  absolutely  dull  on  percussion. 
It  has  a  sharp,  well-defined  edge,  and  a  notch  in  this  which  may  be 
distinguished.  There  is  usually  resonance  between  the  posterior  edge 
and  the  spinal  muscles,  and  there  is  frequently  hollowing  in  this 
position  if  the  tumour  is  large.  Ballottement  cannot  be  obtained. 
The  enlargement  of  a  splenic  tumour  takes  a  downward  and  inward 
direction  ;  that  of  a  renal  tumour  extends  downwards,  not  inwards. 
The  lower  end  of  a  large  splenic  tumour  crosses  the  middle  line  ; 
that  of  a  renal  tumour  does  not,  although  a  very  large  renal  growth 
may  cross  the  middle  line  at  its  point  of  greatest  circumference. 
The  history  of  the  case  and  examination  of  the  blood  may  help. 
Urinary  symptoms,  such  as  hgematuria,  are  very  important  when 
present.  (3)  Ovarian  tumours  are  dull  in  front,  and  there  is  reson- 
ance in  the  flanks.  The  enlargement  has  taken  place  from  below 
upwards.  The  tumour  can  be  felt  in  the  pelvis  from  the  vagina  or 
rectum,  and  there  are  changes  in  the  position  of  the  uterus.  A  small 
ovarian  tumour  with  a  long  pedicle  has  been  mistaken  for  a  renal 
tumour.  (4)  Suprarenal  tumours  are  seldom  distinguished  from 
those  of  the  kidney.  The  kidney  may  be  recognized  as  a  reniform 
swelling  on  the  surface  of  the  mass,  but  if  felt  at  all  will  probably  be 
indistinguishable  from  a  round  nodule  of  growth.  (5)  Maligyiant 
growths  of  the  large  intestine  may  simulate  renal  growths.  In  position 
and  in  distribution  of  the  dullness  they  may  be  similar,  and  the  out- 
line of  the  intestinal  tumour  may  be  rounded  on  palpation.  Mobility 
may  be  a  feature  of  intestinal  growths,  and  it  may  be  possible  to 


Ill]  RADIOGRAPHY  OF  KIDNEY  37 

reduce  such  a  growth  into  the  loin  in  a  manner  similar  to  a  renal 
tumour.  The  presence  of  changes  in  the  urine  or  of  intestinal 
symptoms  will  influence  diagnosis  in  one  or  other  direction.  In- 
testinal growths  are  not  reniform  in  outline.  (6)  Perinephritic 
growths  may  closely  simulate  renal  tumours  in  all  respects,  and 
the  diagnosis  may  only  be  made  by  exploration.  Perinephritic 
iyiflammatiofi  and  suppuration  may  originate  above  a  malignant 
growth  of  the  intestine,  or  may  result  from  appendicitis  or  other 
causes.  The  diagnosis  of  the  cause  of  the  inflammation  will  be 
made  by  the  history  of  the  case. 

II.   RADIOGRAPHY   OF   THE   KIDNEY  AND   RENAL 

PELVIS 

The  Rontgen  rays  were  first  used  in  the  diagnosis  of  renal 
calculus  by  Macintyre  in.  1896,  and  have  proved  of  immense  value 
in  urinary  surgery. 

In  examining  a  kidney  by  this  means  the  plate  should  show 
both  kidney  areas,  the  last  two  ribs  on  each  side,  the  transverse 
processes  of  the  vertebrae,  and  each  iliac  crest,  and  it  should  be 
possible  to  trace  clearly  the  shadow  of  the  psoas  muscle.  If  these 
landmarks  are  not  seen  the  plate  must  be  classed  as  of  poor  quality, 
and  the  value  to  be  placed  upon  the  reading  of  it  is  reduced. 

In  a  plate  of  good  quality  the  shadow  of  a  normal  kidney  can 
be  distinguished.  The  outline  of  the  lower  pole  and  the  outer 
border  are  most  definite ;  the  inner  border  can  sometimes  be 
seen,  but  the  upper  pole  can  seldom  be  distinguished  unless  the 
organ  is  displaced  downwards  clear  of  the  ribs.  The  left  kidney 
throws  a  more  definite  shadow  than  the  right,  which  is  frequently 
obscured  by  the  liver. 

Stoutness  of  the  patient  and  a  loaded  bowel  give  rise  to  diffi- 
culty in  obtaining  a  good  radiogram.  It  is  possible  to  obtain  a 
negative  of  first  quality  even  in  very  stout  subjects.  Careful 
preparation  of  the  bowel  is  of  the  utmost  importance.  A  loaded 
bowel  will  produce  a  cloudy  opacity  which  obscures  the  kidney. 
It  is  equally  important  to  avoid  over-purgation,  as  the  large  in- 
testine becomes  distended  with  air  and  reduces  the  value  of  the 
plate.  A  mild  aperient,  such  as  a  dose  of  hquorice  powder,  should 
be  given  on  two  successive  nights  previous  to  the  examination. 
The  patient  should  eat  very  sparingly  on  the  day  before,  and  should 
fast  on  the  day  of  the  examination. 

It  is  important  for  purposes  of  localization  and  comparison 
that  the  radiographer  should  be  able  to  reproduce  with  mathe- 
matical exactness  the  position  and  the  relation  to  each  other  of  the 
patient,  the  tube,  and  the  plate  at  any  subsequent  time,  and  in 


38  THE   KIDNEY  [chap. 

order  to  do  this  a  fixed  position  must  be  used.  The  radiographer 
must  clearly  indicate  on  the  plate  which  is  the  right  and  which 
the  left  side  of  the  patient. 

At  the  first  examination  both  kidney  areas  should  be  examined, 
and  the  light  should  be  centrally  placed  in  relation  to  the  patient. 
Should  more  detailed  information  be  required  to  elucidate  some 
point,  oblique  rays  may  be  used,  or  one  spot  may  be  examined 
by  means  of  a  diaphragm.  Inspection  with  the  fluorescent  screen 
may  be  used  as  a  preliminary  to  the  production  of  a  radiogram, 
but  it  is  an  unreliable  method  of  examination  and  cannot  replace 
radiography.  The  photographic  negatives  should  be  examined  in 
preference  to  prints  in  doubtful  cases. 

It  cannot  be  too  strongly  insisted  that  every  radiographic  ex- 
amination in  urinary  disease  must  include  the  whole  urinary  tract. 
Both  kidneys,  both  ureters,  the  bladder,  and  the  urethra  must  be 
examined. 

Radiography  in  Eenal  Calculus 

Radiography  is  used  for  the  following  purposes  in  renal  cal- 
culus : — 

1.  Diagnosis  of  the  calculus. 

2.  Examination  of  the  condition  of  the  calculous  kidney. 

3.  Localization  of  the  calculus. 

4.  Examination  of  the  second  kidney. 

1.  Diagnosis  of  renal  calculus,  (a)  Position  of  the  shadow. — 
In  the  radiogram  the  bodies  of  the  vertebrae  and  transverse  processes, 
the  last  two  ribs,  and  the  iliac  crests  will  be  visible,  and  these 
act  as  landmarks.  The  following  points  in  regard  to  the  normal 
relations  of  the  kidney  to  the  bony  skeleton  are  therefore  extreniely 
important.  The  upper  part  of  the  kidney  lies  under  cover  of  the 
last  two  ribs,  the  upper  border  corresponding  to  the  middle  of 
the  11th  dorsal  vertebra  and  being  covered  by  the  shadow  of  the 
11th  rib.  This  rib  may  therefore  be  taken  as  representing  the  upper 
limit  of  the  renal  area.  The  lower  border  reaches  the  level  of  the 
lower  border  of  the  transverse  process  of  the  3rd  lumbar  vertebra. 
The  right  kidney  lies  a  little  lower  than  the  left.  In  radiograms 
the  lower  border  of  the  kidney  usually  comes  a  little  lower  than 
this,  and  the  upper  border  scarcely  so  high.  The  outer  border 
usually  lies  well  beyond  the  tip  of  the  12th  rib,  but  the  varying 
length  and  obliquity  of  this  rib  make  it  an  unreliable  guide. 

I  have  adopted  the  following  method  of  measurement  by  which 
the  outer  border  of  the  normal  kidney  can  be  indicated  and  any 
increase  in  size  demonstrated.  If  the  narrowest  transverse  measure- 
ment of  the  1st  lumbar  vertebra  be  taken,  and  this  measurement 


Fig.  1. — Shadow  thrown  by  gall-stone  in  renal  area  (upper  arrow)  ; 
shadow  of  right  lobe  of  liver  (lower  arrow).      (P.  39.) 

Fig.  2. — Shadows  thrown  by  bismuth-covered  feeces  during  adminis- 
tration of  bismuth.     (P.   41.) 

Fig.  3. — Shadow  thrown  by  intra-abdominal  calcareous  glands. 
The  shadow  lies  on  the  psoas-muscle  shadow  at  the  level 
of  pelvis  of  kidney,  but  just  internal  to  it.     (P.  39.) 


Plate  l. 


ni]      RADIOGRAPHY   IN    RENAL   CALCULUS      -'^'-^ 

doubled  and  projected  transversely  tVoni  the  middle?  of  the  outer 
edge  of  the  vertebral  body,  a  point  will  be  found. 

If  the  same  measurements  be  made  in  regard  to  the  2nd  and 
3rd  lumbar  vertebrae,  two  other  points  are  found.  By  joining 
these  three  points  the  outer  border  of  the  kidney  is  roughly  in- 
dicated. The  kidney  does  not,  however,  lie  flat  on  an  even  bed 
of  muscle.  The  inner  border  is  tilted  so  that  the  hilum  and  pelvis 
face  forwards  and  inwards.  As  a  result,  shadows  of  calculi  lying 
in  the  pelvis  of  the  kidney  may  appear  in  the  kidney  area  as  if 
embedded  in  the  substance  of  the  organ. 

The  inner  border  of  the  kidney  corresponds  with  fair  accuracy 
to  the  outer  border  of  the  psoas  shadow,  and  the  hilum  lies  in  this 
line  at  the  level  of  the  2nd  lumbar  vertebra.     The  pelvis  of  the 
kidney  lies  at  this  area  and  over- 
laps the  psoas  shadow.     In  full  ex- 
piration and  in  full  inspiration,  in 
the  supine  and  in  the  erect  posture, 
the    kidney    shadow    lies  higher    or 
lower    respectively,    and     in     some 
cases  the  excursion  is  considerable. 

Shadows  in  the  renal  area  are, 
so  far  as  position  is  concerned,  most 
probably  calculi  embedded  in  the 
kidney  (Plate  20,  Figs.  1,  2)  ;  those 
in  the  pelvic    area    are    stones    in 

the  renal  pelvis.  Lying  outside  and  pjg^  16.— Gall-stone  which 
below  the  kidney  is  the  colon,  and  threw     a      radiographic 

this    also    passes    in    front    of   the  shadow  in  renal  area. 

kidney,    so   that   opaque    bodies   in 

the  colon  may  give  shadows  in  the  renal  area.  This  difhculty 
more  frequently  arises  on  the  left  side,  where  the  colon  covers  a 
larger  area  of  the  kidney,  than  on  the  right.  This  does  not  affect 
the  pehdc  area,  but  in  this  area  calcified  glands  in  the  lumbar 
chain  or  in  the  mesentery  may  throw  shadows  (Plate  1,  Fig.  3). 
Immediately  outside  the  renal  area  on  the  right  side  at  the  level  of 
the  1st  lumbar  vertebra  are  the  gall-bladder  and  ducts.  Rarely,  a 
shadow  may  be  throwii  by  a  gall-stone  and  appear  in  this  area. 
Plate  1,  Fig.  1,  shows-  the  shadow  of  a  gall-stone  which  I  re- 
moved from  the  cystic  duct ;  Fig.  16  shows  the  gall-stone  itself. 
The  patient  had  been  unsuccessfully  explored  for  renal  calculus  in 
South  Africa. 

The  kidney  which  contains  a  calculus  may  be  movable  or  dis- 
placed. When  the  outhne  of  the  kidney  is  seen  in  the  negative 
the  relations  of  the  suspected  stone  shadow  to  it  will  be  evident. 


• 


40 


THE   KIDNEY 


[chap. 


The  displacement  is  usually  vertical ;  seldom,  if  ever,  outward. 
A  stone  in  the  pelvis  of  a  horseshoe  kidney  is  much  nearer  the 
middle  line  than  the  normal  pelvis,  and  is  usually  at  a  lower  level. 
After  an  operation  upon  the  kidney  the  organ  is  usually  found 
displaced  downwards,  and  may  be  partly'  hidden  behind  the  shadow 
of  the  iliac  crest. 

Distension  of  the  renal  pelvis  with  coUargol  solution  (Pyelography, 
p.  42)  may  give  valuable  assistance  in  localizing  a  doubtful  shadow. 

(b)  Size,  shape,  and  number. — Small  stones  usually  throw 
a  round  or  oval  shadow.  Stones  the  size  of  a  split  pea  may  be 
recognized  unless  composed  of  pure  uric  acid.     The  size  of  the 

shadow     is     several 
times     greater    than 
that  of  the  stone,  if 
the  stone  be  opaque 
throughout.       Move- 
ment of  the  stone  due 
to  deep  breathing  will 
cause  a  round  stone 
to  throw  an  elongated 
shadow.   When  a  pro- 
longed   exposure  has 
been  given,  some  very 
small     stones,   which 
are  eventually  passed 
through  the  ureter,  do 
not  cast  a  shadow  on 
even  a  good  plate. 
Large  stones  are  usually  branched,  and  the  main  mass  throws 
an  extensive,  heavy  shadow  (Plate  20,  Fig.  1,  and  Fig.  17).     The 
branches   which   are   connected   by  a  narrow  neck   may  appear 
isolated.     In  the  larger  masses  of  stone  the  shadows  extend  down- 
wards beyond  the  kidney  area,  and  may  be  partly  hidden  by  the 
iliac  crest.     A  collection  of  stones  may  throw  a  single  shadow. 

(c)  Density  of  the  shadow. — The  density  of  the  shadow 
depends  upon  the  size  and  composition  of  the  calculus.  A  large 
mass  of  calculus  will  throw  a  heavy,  uniform  shadow,  whatever 
its  composition  may  be ;  a  small  calculus  will  throw  a  shadow 
whose  definition  and  opacity  depend  upon  its  composition.  ,  Oxalate- 
of-lime  stones  are  the  least  permeable  to  the  rays  and  throw  the 
densest  shadow,  the  rare  cystin  and  xanthin  calculi  throw  a  shadow 
slightly  less  dense,  calcium  phosphate  is  next,  and  triple  phosphate 
is  much  less  opaque.  Pure  uric-acid  stones  throw  little,  if  any, 
shadow,  and  are  not  recognizable  in  the  body.     Calculi  are  seldom 


Fig.  17.- 


-Branched  calculi  removed  from 
kidney. 


in]      RADIOGRAPHY  IN   RENAL  CALCULUS      41 

composed  of  a  single  ingredient,  and  a  coating  of  phosphates  will 
occasionally  render  a  uric-acid  calculus  opaque. 

Fallacies. — Fallacies  due  to  the  size  and  composition  of  a  cal- 
culus have  already  been  noted.  Opaque  substances  in  the  bowel 
may  closely  simulate  renal  calculi.  A  shadow  of  very  irregular 
shape  is  unlikely  to  be  caused  by  a  calculus.  Sometimes  the  shape 
is  that  of  some  recognizable  object,  such  as  a  coin.  A  long,  opaque 
body  lying  transversely  is  not  renal,  and  is  usually  in  the  bowel. 

In  a  patient  who  has  been  taking  bismuth,  shadows  which  are 
indistinguishable  in  size,  shape,  position,  and  density  from  those 
of  renal  or  pelvic  calculi  may  be  thrown  by  bismuth-covered  faeces. 
The  bismuth  shadows  shown  in  Plate  1,  Fig.  1,  remained  for 
several  months,  in  spite  of  repeated  purgation. 

Calcified  glands  belonging  to  the  lumbar  group  or  Ipng  in  the 
mesentery,  or  the  deposit  of  phosphates  upon  silk  ligatures  used 
in  a  previous  operation,  may  simulate  renal  or  pelvic  calculi.  In- 
definite shadows  are  sometimes  found  in  the  kidney  or  pelvic  area, 
which  have  proved  to  be  due  to  thickened  scars  in  the  kidney  or 
to  phosphatic  deposit  in  an  inflamed  or  tuberculous  renal  pelvis. 

Fallacy  due  to  gall-stones  has  already  been  mentioned. 

In  an  aseptic  case  the  absence  of  a  stone  shadow  after  two  or 
more  examinations,  when  a  plate  of  first  quality  has  been  obtained, 
excludes  all  but  a  pure  uric-acid  calculus. 

When  the  urine  is  alkaline  the  absence  of  a  stone  shadow  excludes 
calculi  of  any  composition,  for  it  is  certain  that  phosphates  will 
have  been  deposited  upon  a  uric-acid  calculus  and  render  it  opaque. 

2.  Condition  of  the  kidney.— In  slight  dilatation  of  the 
kidney  the  measurement  given  above  will  serve  roughly  to  demon- 
strate the  change.  I  have  introduced  a  more  accurate  method 
of  measurement  of  the  kidney  shadow.  A  ureteric  catheter,  alter- 
nately opaque  and  translucent  in  segments  of  half  an  inch,  is  passed 
up  the  ureter  of  the  diseased  kidney  ;  on  the  plate  the  shadow- 
value  of  half  an  inch  is  obtained,  and  by  using  this  the  shadow 
of  the  kidney  can  be  measured  in  half-inches. 

In  a  greatly  enlarged  calculous  kidney  the  shadows  extend 
downwards  and  outwards  beyond  the  normal  limits. 

The  stone  shadows  may  merge  with,  and  be  partly  hidden  by, 
the  iliac  shadow.  The  upper  limit  does  not,  however,  extend 
higher  than  the  normal  kidney  at  the  level  of  the  11th  rib. 

Where  a  very  large  branched  shadow  or  many  stone  shadows 
are  observed,  the  kidney  will  be  found  practically  destroyed. 

Isolated  stone  shadows  widely  separated  indicate  that  the  kid- 
ney is  dilated  with  pus  or  urine,  and  a  large  kidney  outline  will 
confirm  this. 


42  THE   KIDNEY  [chap. 

The  use  of  collargol  in  the  diagnosis  of  hydronephrosis  will  be 
described  later  (p.   176). 

3.  Position  of  the  calculus. — Several  cases  are  recorded  in 
which  symptoms  of  stone  were  present  in  one  kidney,  and  radio- 
graphy showed  that  this  kidney  was  free  from  calculus,  but  that 
the  second  kidney  was  the  seat  of  calculi. 

Shadows  lying  far  out  in  the  kidney  area  are  cast  by  calculi 
embedded  in  the  calyces,  and  the  position  of  the  shadow  will 
indicate  whether  the  stone  lies  at  the  upper  or  the  lower  pole  of 
the  kidney.  A  stone  shadow  lying  over  or  above  the  12th  rib 
shadow  and  far  out,  in  a  short,  stout  patient,  is  likely  to  give  rise 
to  difficulty  in  its  removal. 

Pyelography  is  valuable  in  accurately  localizing  the  position  of 
the  calculus. 

4.  Examination  of  the  second  kidney. — When  a  stone 
shadow  has  been  found  in  one  kidney,  information  in  regard  to  the 
second  kidney  may  be  obtained  by  examination  of  the  plate.  If 
the  outline  of  this  kidney  is  seen  and  is  normal,  this  will  demon- 
strate the  presence  of  a  second  kidney,  although  it  will  not  indicate 
functional  power.  The  most  frequent  disease  of  the  second  kidney, 
when  one  organ  is  the  seat  of  calculus,  is  the  formation  of  calculi, 
and  the  absence  of  stone  shadows  in  the  kidney  will  exclude  this. 

Radiogeaphy  in  Hydronephrosis  and  Pyonephrosis 

A  large,  dense  shadow  is  thrown  by  a  distended  kidney.  The 
upper  and  inner  parts  are  difhcult  to  define,  but  there  is  a  sharp 
and  easily  distinguishable  outer  and  lower  border.  It  is  impossible 
to  distinguish,  in  a  radiograph,  between  a  hydro-  and  a  pyonephrosis. 

Pyelography  (Plates  2,  3,  4). — Voelcker  and  Lichtenberg 
introduced  a  method  by  which  the  early  stages  of  dilatation  of  the 
renal  pelvis  can  be  recognized.  These  observers  inject  a  warm 
solution  (2  to  5  per  cent.)  of  collargol,  an  innocuous  preparation  of 
silver,  through  a  ureteric  catheter  into  the  renal  pelvis.  A  radio- 
gram is  now  made,  and  the  size  and  shape  of  the  renal  pelvis  can 
be  seen.  Lime-water,  argyrol,  and  other  solutions  have  also  been 
used,  but  are  less  opaque.  I  have  used  this  method  in  a  large 
number  of  cases,  and  have  obtained  striking  pictures  of  the  renal 
pelvis  which  clearly  demonstrate  the  position  of  the  pelvis  and 
the  presence  or  absence  of  dilatation. 

A  catheter  is  passed  up  the  ureter  so  that  the  eye  enters  the 
renal  pelvis,  and  the  contents  are  allowed  to  run  off.  The  bladder 
is  emptied  and  the  cystoscope  removed,  leaving  the  ureteric  catheter 
in  position.  The  collargol  solution  is  heated  and  slowly  introduced. 
I  use  a  10  or  a  20  per  cent,  solution,  and  introduce  it  by  means 


Fig.  1. — Pyelography  :  Injected  pelvis  showing  dichotomous  out- 
line and  calyces.  Note  axis  of  upper  end  of  ureter  and 
of  pelvis  are  in  line.     (P.   42.) 

Fig.  2. — Pyelography  :  Collargol  which  has  regurgitated  into  bladder 
(arrow).     Opaque  catheter  in  ureter,     (P.  42.) 

Fig.  3. — Pyelography  in  movable  kidney:  Kinking  of  ureter  and 
dilatation  of  upper  calyx.  The  lowermost  arrow  points  to 
the  upper  end  of  ureter,  the  middle  one  to  the  kinked 
pelvo-ureteral  junction,  and  the  uppermost  one  to  the 
dilated  calyx.     (Pp.   79,  176.) 


Plate  2. 


Ill]  PYELOGRAPHY  43 

of  an  all-glass  syringe  of  20  c.c.  capacity.  The  barrel  of  the  syringe, 
filled  with  solution  and  with  the  piston  in  place,  is  attached  to  the 
catheter  by  means  of  the  needle,  and  held  6  in.  to  1  ft.  above  the 
level  of  the  body.  The  fluid  passes  slowly  in,  and  is  assisted  by 
an  occasional  touch  on  the  piston.  No  force  is  used,  and  the 
injection  is  stopped  whenever  the  patient  feels  the  pain  of  dis- 
tension of  the  pelvis ;  the  syringe  is  removed,  the  catheter  plugged, 
and  the  radiograph  is  taken.  The  ureteral  catheter  should  be 
opaque  to  the  X-rays.  The  fluid  is  now  allowed  to  flow  oii.  The 
catheter  is  removed  in  ten  minutes.  Pain  is  usually  only  present 
when, the  pelvis  is  fully  distended,  but  occasionally  there  is  an 
attack  of  renal  colic.  In  the  radiographic  plate  the  uretero-pelvic 
junction  should  be  examined  for  kinking,  and  the  pelvis  and  calyces 
for  dilatation.  The  earliest  stage  of  dilatation  is  shown  by  club- 
bing of  the  calyces.  .  Later,  the  calyces  become  much-  enlarged 
and  approach  the  surface  of  the  kidney,  and  the  kidney  tissue 
between  them  is  reduced  (Plate  3,  Fig.  1).  The  angle  formed 
between  the  lowest  calyx  and  the  ureter  and  pelvis  becomes  more 
and  more  acute  as  dilatation  proceeds,  and  eventually  there  is  only 
a  narrow  slit  remaining  (Plate  3,  Figs.  1,  3).  A  hydronephrosis 
shows  as  a  mass  of  opaque  nodules  separated  by  thin,  clear  lines — 
renal  type  (Plate  4,  Fig.  1) ;  or  as  a  large  opaque  mass  with  small 
bosses  projecting  from  its  surface— pelvic  type  (Plate  3,  Figs.  2,  3). 
In  the  normal  kidney  the  point  of  the  ureteric  catheter  enters 
the  upper  calyx  of  the  renal  pelvis,  and  can  be  seen  here  in  a 
collargol  plate  (Plate  4,  Fig.  3).  In  hydronephrosis  the  catheter 
impinges  on  the  upper  wall  of  the  dilated  pelvis  (Plate  3,  Fig.  3). 

Braasch  has  recorded  cases  of  renal  tumour,  tuberculosis,  and 
other  renal  diseases  in  which  he  has  used  the  method. 

Radiography  in  Renal  Tuberculosis 

Clark,  Brown,  and  others  have  shown  that  radiographic  shadows 
are  thrown  by  chronic  tuberculous  "  abscesses "  of  the  kidney. 
The  opacity  depends  in  part  upon  the  presence  of  phosphatic  salts 
in  the  milky  or  putty-like  substance  found  in  these  "  abscesses," 
but  also  upon  the  greater  bulk  of  the  kidney  which  contains  these 
collections.  In  Plate  5,  facing  p.  58,  are  shown  the  outhne  and 
details  of  structure  of  a  tuberculous  kidney  converted  into  a  multi- 
locular  sac  filled  with  putty-like  material. 

Radiography  in  New  Growths  of  the  Kidney 

Large  growths  of  the  kidney  cast  a  dense,  ill-defined  shadow 
which  extends  beyond  the  normal  limits  of  the  kidney. 


44  THE   KIDNEY  [chap. 

Dangers  of  Radiography 

All  possible  care  must  be  exercised  by  the  radiograpber  in 
avoiding  undue  exposure  of  the  patient,  rough  handling,  or  too 
severe  pressure  upon  the  kidney.  I  have  seen  a  severe  attack  of 
haematuria  with  an  increase  in  all  the  symptoms  follow  a  radio- 
graphic examination  of  a  tuberculous  kidney,  and  a  serious  crisis  of 
fever  and  reduced  renal  function  supervene  in  bilateral  calculous 
disease. 

The  collargol  method  must  be  used  with  the  greatest  possible 
care  and  gentleness,  and  is  only  safe  and  reliable  in  the  hands  of 
an  expert. 

LITERATURE 

Blum,  Amer.  Journ.  Derm,  and  Gen.-Urin.  Dis.,  March,  1912,  p.  136. 

Braasch,  Ann.  Surg.,  Noy.,  1910,  p.  645. 

Brown,  New  York  Med.  Journ.,  March  31,  1906,  p.  683. 

Clark,  Med.  News,  Dec.  9,  1905. 

Keyes,  Trans.  Amer.    Urol.  Assoc,  1909,  p.  351. 

Macintyre,  Lancet,  July  11,  1896. 

Voelcker  und  Lichtenberg,  Miinch.  med.   Woch.,  Jan.    16,  1906 ;     Beitr.  Hin. 

Chir.,  1907,  lii.  1. 
Walker,  Thomson,  Lancet,  June  17,  1911  ;    Travis.  Med.  Soc.  Lond.,  1912. 

III.   EXAMINATION   OF   THE   BLADDER   IN   SURGICAL 
DISEASES   OF   THE   KIDNEY 

The  examination  of  most  surgical  diseases  of  the  kidney  is 
incomplete  without  examination  of  the  bladder  with  the  cystoscope. 
The  method  of  performing  cystoscopy  will  be  described  in  the 
section  dealing  with  diseases  of  the  bladder. 

The  cystoscope  may  be  required  to  localize  the  disease. 

There  may  be  disease  of  the  bladder  which  has  caused  no  vesical 
symptoms  but  has  given  rise  to  symptoms  pointing  to  disease  of 
the  kidney.  When  a  papilloma  of  the  bladder  is  seated  at  one 
ureteric  orifice  there  is  often  pain  in  the  kidney  on  that  side,  and 
this,  combined  with  haematuria  from  the  papilloma,  may  cause  a 
diagnosis  of  renal  heematuria  to  be  made  if  the  cystoscope  is  not 
used.  This  is  especially  the  case  when  the  ureter  and  kidney  are 
dilated  from  obstruction  by  a  growth  in  the  bladder.  In  such  a 
case  there  is  a  painful  enlarged  kidney  with  haematuria,  and  with- 
out cystoscopy  the  kidney  may  be  regarded  as  the  source  of  the 
haematuria. 

In  tuberculosis  and  other  diseases  of  the  kidney  there  may  be 
signs  of  cystitis  with  no  symptoms  of  disease  of  the  kidney.  The 
secondary  nature  of  the  vesical  disease  will  be  demonstrated  by 
the  condition  of  the  ureteric  orifice  and  area  surrounding  it  and 
the  efflux. 


j.ii.-m^^ 

^^^^K£^^___ 

Fig.  1. — Dilated  calyces  in  ureteral  calculus.  (Pp.  43,  176.) 
Fig.  2. — Hydronephrosis  caused  by  aberrant  renal  vessels.  Dilated 
renal  pelvis  shown  by  oval  collargol  shadow.  (Pp.  43,  176.) 
Fig.  3. — Hydronephrosis  (pelvic  type)  in  movable  kidney.  Three 
arrows  point  to  ureter  ;  the  upper  and  lower  to  segments 
filled  with  collargol,  the  middle  to  an  empty  segment, 
probably  a  descending  wave  of  contraction.  The  outer 
arrow  points  to  the  dilated  kidney,  the  uppermost  one 
to  the  greatly  dilated  pelvis.     (Pp.  43,   176.) 


Plate  3. 


Fig.   1. — Double  hydronephrosis.       On  the  left  is  a  hydronephrotic 

kidney  filled  with  collargol.     The  clear  bands  (lower  arrow) 

I   indicate  the  fibrous   septa.     On  the  right  is  a   very  large 

hydronephrosis,  the  arrows  pointing  to  shadows  of  widely 

separated  calculi  in  the  kidney.     (Pp.  43,   176.) 

Fig.  2. — Pyelography  :  Normal  trumpet-shaped  pelvis  and  calyces. 
Arrows  point  to  catheter  in  ureter,  open  angle  between  this 
and  lower  calyx,  upper  and  lower  calyces.     (Pp.  43-6.) 

Fig.  3. — Pyelography:  Normal  trumpet-shaped  pelvis  with  calyces. 
The  point  of  the  opaque  catheter  (arrow)  is  lying  in  the 
upper  calyx.  An  arrow  points  to  the  lower  calyx,  and 
another  to  the  open  angle  between  this  and  the  ureter 
and  pelvis.     (P.   176.) 


Plate  4. 


Ill]  CYSTOSCOPY  IN   RENAL   DISEASE  45 

In  many  cases  of  pyuria  and  hseraaturia  there  are  no  definitely 
localizing  symptoms,  and  cystoscopy  is  necessary  to  exclude 
disease  of  the  bladder.  In  these  cases  a  blood-stained  or  purulent 
efflux  will  indicate  the  kidney  as  the  source  of  the  haematuria  or 
pyuria,  and  show  which  side  is  diseased. 

Information  may  bo  obtained  as  to  the  state  of  the  diseased 
kidney  by  observing  the  ureteric  orifice.  An  open,  rigid  ureteric 
orifice  denotes  dilatation  of  the  ureter  and  renal  pelvis.  A 
"  dragged-out "  ureteric  orifice  (Fenwick)  is  present  in  cases  of 
advanced  tuberculosis  of  the  kidney  or  ureter.  Here  the  orifice 
is  displaced  outwards  and  upwards,  and  resembles  a  tunnel.  In 
cases  where- the  efflux  is  a  semi-solid  pipe  of  pus  the  kidney  is 
functionally  destroyed  and  is  converted  into  a  thin- walled  sac. 
Large  quantities  of  purulent  urine  are  poured  out  of  the  ureteric 
orifice  in  cases  of  acute  and  subacute  pyelonephritis.  A  cloudy 
efflux  is  present  in  the  minor  grades  of  pyelitis.  Where  no  efflux  is 
present  on  one  side,  and  the  cause  is  not  some  temporary  cessation 
of  the  renal  function,  the  kidney  may  be  absent  on  that  side,  or 
the  ureter  may  be  blocked  by  kinking  -or  some  other  cause,  or 
there  may  be  a  fistula  of  the  ureter. 

When  the  kidney  is  absent  or  totally  destroyed,  there  will  be 
no  movement  at  the  ureteric  orifice.  When  the  kidney  is  present 
and  secreting,  and  the  ureter  blocked,  there  will  be  an  occasional 
•  sluggish  movement  at  the  orifice,  although  there  is  no  efflux.  In 
the  case  of  a  fistula  of  the  ureter  the  rhythm  and  force  of  the 
movements  at  the  ureteric  orifice  may  be  normal,  although  there 
is  no  discharge  of  urine  into  the  bladder.  Lastly,  information  may 
be  gained  in  regard  to  the  presence  and  condition  of  a  second 
kidney  when  one  is  diseased.  The  absence  of  a  ureteric  orifice 
on  one  side  will  usually  denote  the  absence  of  the  kidney  on  that 
side.  The  muscle  of  the  trigone  on  the  side  corresponding  to  the 
congenitally  absent  ureter  is  often  absent.  Rarely,  the  ureter 
may  open  in  some  abnormal  situation,  such  as  the  prostatic  urethra. 

The  presence  of  a  normally  placed  ureter  and  the  observation 
of  an  efflux  from  it  mil  in  all  but  the  rarest  cases  demonstrate  the 
presence  of  a  kidney  on  that  side. 

In  very  rare  cases  two  normally  placed  ureteric  orifices  lead  to 
the  ureters  of  a  solitary  kidney,  one  of  the  ducts  crossing  the 
middle  line.  In  such  a  case  the  condition  may  be  demonstrated 
by  passing  an  opaque  bougie  into  the  ureter  and  obtaining  a 
radiogram,  or  by  pyelography. 

When  there  is  disease,  such  as  tuberculosis  of  one 'kidney  and 
the  bladder,  the  area  of  bladder  mucous  membrane  around  the 
ureteric  orifice  of  the  second  kidney,  and  the  orifice  itself,  may  be 


46  THE   KIDNEY  [chap,  in 

free  from  disease.  This  is  strong  evidence  but  not  absolute  proof 
that  the  second  kidney  is  not  tuberculous.  If  the  eflELux  is  clear 
on  this  side,  this  is  further  evidence,  but  it  is  necessary  to  examine 
the  urine  of  this  kidney  separately  in  order  to  make  certain  of 
the  health  of  the  organ. 

Examination  of  the  urine  of  each  kidney.— In  rare  cases 
when  there  is  known  to  be  complete  blocking  of  one  kidney,  or 
when  a  fistula  drains  away  the  urine  from  one  kidney,  it  may  be 
assumed  that  the  urine  passed  through  the  bladder  is  derived  from 
the  other  kidney,  and  examination  of  this  urine  will  demonstrate 
the  condition  of  the  kidney.  In  all  other  cases  the  urine  which  is 
passed  is  a  blend  of  that  secreted  by  the  two  kidneys. 

In  order  to  examine  the  functional  activity  of  one  kidney,  and 
frequently  to  locahze  disease  to  one  kidney,  it  is  necessary  to  examine 
the  secretion  of  each  organ  separately.  The  urine  of  each  kidney 
is  obtained  by  means  of  separators  or  ureteric  catheters  (p.  367). 

Exploration  of  the  kidney.— Exploration  of  the  kidney  by 
operation  may  be  necessary  in  the  following  cases : — 

1.  To  make  a  diagnosis  in  an  abdominal  tumour  of  doubtful 
nature.     Laparotomy  will  be  the  best  method. 

2.  To  ascertain  the  nature  of  disease  already  localized  to  the 
kidney.  An  oblique  lumbar  incision  and  extraperitoneal  examina- 
tion of  the  kidney  is  the  method  best  suited  to  this  purpose. 

3.  To  ascertain  the  extent  and  connections  and  the  condition 
of  the  lymphatics  in  a  malignant  growth  of  the  kidney  which  has 
reached  a  considerable  size.  Either  a  combined  lumbar  extra- 
peritoneal examination  of  the  kidney  with  an  extraperitoneal 
exploration  through  an  opening  in  the  peritoneum  in  front  of  the 
colon,  or  a  laparatomy  alone,  may  be  used. 

4.  To  ascertain  the  presence  and  condition  of  the  second  kidney 
when  one  is  diseased  and  nephrectomy  is  proposed.  Exploration 
of  the  kidney  for  this  purpose  can  only  be  necessary  in  the  rarest 
cases.  Cystoscopy  and  catheterization  of  the  ureters  have  taken 
the  place  of  this  operation,  and  it  is  only  when  these  methods  are 
rendered  impossible  by  inflammation  of  the  bladder  that  this  opera- 
tion is  required.  In  some  cases  of  tuberculosis  of  the  kidney  and 
bladder,  when  the  bladder  has  been  too  irritable  to  permit  of  catheter- 
ization of  the  ureters,  a  course  of  tuberculin  injections  lasting 
three  months  has  caused  sufficient  improvement  to  allow  of  ureteral 
catheterization.  Exploration  of  the  kidney  in  such  cases  is  carried 
out  through  a  lumbar  incision,  and  the  kidney  is  examined  by 
inspection,  'palpation,  and  incision,  and  a  shp  of  the  kidney 
substance  is  examined  microscopically.  The  abdominal  route  only 
permits  of  palpation,  and  has  been  proved  to  be  worthless. 


CHAPTER  IV 
ABNORMAL  CONDITIONS  OF  THE  URINE 

OXALURIA 

About  0-0172  grm.  of  oxalic  acid  is  passed  daily  in  the  urine  as 
calcium  oxalate.  This  is  derived  from  the  food,  and  partly  also 
from  the  tissues.  It  is  -held  in  solution  by  the  acid  phosphate  of 
sodium  of  the  urine.  Calcium  oxalate  is  deposited  in  the  form  of 
octahedra  or  dumb-bell  crystals,  which  are  visible  to  the  naked 
eye  as  sparkling  particles  in  clear  urine.  The  urine  is  usually  pale 
and  faintly  acid.  When  calcium  oxalate  appears  in  a  high-coloured 
urine  it  is  said  to  result  from  the  decomposition  of  urea,  and  is  of 
no  clinical  importance.  Crystals  of  calcium  oxalate  are  some- 
times passed  persistently  for  years  with  occasional  attacks  of  severe 
oxaluria.  Small  masses  of  crystals  clinging  loosely  together  may 
be  passed,  and  larger  masses  bound  together  with  a  colloid  sub- 
stance form  calculi. 

Increased  excretion  of  oxalic  acid  has  been  observed  in  jaundice, 
diabetes,  gastritis,  enteritis,  and  pancreatitis,  but  is  not  constant 
in  any  disease.  A  deposit  of  these  crystals  may  take  place  after 
eating  certain  vegetables,  such  as  rhubarb,  spinach,  tomatoes, 
sorrel,  and  gooseberries. 

In  many  cases  persistent  oxaluria  is  accompanied  by  symptoms 
of  dyspepsia  and  mental  depression,  or  even  neurasthenia.  The 
exact  relationship  of  these  symptoms  to  the  oxaluria,  whether 
they  are  the  cause  or  the  effect,  is  not  decided. 

The  symptoms  which  are  directly  caused  by  the  presence  of 
large  quantities  of  oxalate-of-lime  crystals  in  the  urine  are  due 
to  irritation  of  the  kidneys  and  urinary  tract.  Renal  aching  is 
frequently  present,  and  is  usually  bilateral.  It  may,  however,  be 
more  marked  on  or  even  confined  to  one  side.  Aching  along  the  line 
of  the  ureter  may  also  be  felt.  Unilateral  renal  colic  may  result 
from  the  passage  of  large  quantities  of  oxalate  crystals.  The  colic 
may  be  severe,  and  is  indistinguishable  from  that  caused  by  the 
passage  of  a  calculus  down  the  ureter.  Heematuria  may  accom- 
pany the  colic,  and  the  blood  is  present  in  considerable  quantities. 

47 


48  THE   KIDNEY  [chap. 

In  less  pronounced  cases  of  oxaluria,  blood  discs  are  frequently 
found  microscopically,  when  no  staining  of  the  urine  is  perceptible 
to  the  naked  eye. 

Some  vesical  irritation  is  usually  present  in  oxaluria,  and  fre- 
quency of  micturition  may  be  the  prominent  symptom. 

When  an  oxalate- of -lime  stone  is  present,  oxaluria  may  be 
pronounced ;  but,  on  the  other  hand,  there  may  be  only  a  few 
crystals  or  none  at  all. 

All  the  symptoms  of  a  calculus  of  the  kidney,  ureter,  or  bladder 
may  be  simulated  by  oxaluria.  Exercise  does  not,  however,  affect 
the  symptoms  in  the  latter  condition.  Cystoscopy  will  show  that 
no  calculus  is  present  in  the  bladder,  and  the  X-rays  fail  to  demon- 
strate a  stone  in  the  kidney  or  ureter.  , 

Treatment. — The  diet  should  contain  little  oxaUc  acid  and 
lime,  and  plenty  of  magnesia,  for  the  latter  favours  solution  of 
calcium  oxalate.  The  bowels  should  be  regulated,  and  all  causes 
of  intestinal  fermentation  removed.  Articles  of  diet  that  are  rich 
in  oxalic  acid,  and  therefore  contra-indicated,  are  rhubarb,  spinach, 
tomatoes,  sorrel,  gooseberries,  strawberries,  tea,  coffee,  pepper, 
haricots,  beetroot,  and  dried  figs,  much  milk,  quantities  of  carbo- 
hydrates in  the  form  of  sugar  and  sweets.  Calcium  is  in  excess  in 
the  following  foods,  which  should  therefore  be  avoided,  viz.  veal, 
milk,  eggs,  fresh  vegetables  such  as  radishes,  asparagus,  spinach, 
cereals  (especially  rice),  and  hard  water. 

Foods  poor  in  lime,  and  therefore  suitable,  are  meat  (except 
veal),  fish,  bread,  fruit,  potatoes.  Magnesium  is  abundant  in  meat, 
bread,  potatoes,  peas,  apples,  and  beer,  and  these  articles  may 
be  taken. 

Mineral  acids,  such  as  dilute  nitro-hydrochloric,  should  be  given, 
combined  with  strychnine.  The  acidity  of  the  urine  should  be 
increased  by  the  administration  of  acid  phosphate  of  sodium,  which 
is  the  natural  solvent  of  the  oxalate  of  lime  in  the  urine.  It  should 
be  dissolved  in  a  large  quantity  of  water  and  taken  between  meals 
in  a  dose  of  |  oz.  to  1  oz.  daily.  It  occasionally  causes  troublesome 
diarrhoea,  and  the  quantity  may  have  to  be  reduced  on  this  account. 
When  much  irritation  is  present,  sandal- wood  oil  in  capsules  (10 
minims  thrice  daily)  and  a  diluent  water  such  as  barley  water 
may  be  given  for  a  week  at  first,  and  the  acid  treatment  commenced 
after  the  most  acute  symptoms  have  subsided. 

Mineral  waters  which  contain  little  lime,  or  such  as  are  rich 
in  magnesium  and  sodium  phosphates,  should  be  given.  To  the 
former  belong  Contrexeville  and  Vittel,  and  to  the  latter  Kissingen. 
Hard  water  should  be  avoided,  and  also  such  mineral  waters  as 
contain  lime  (Rosbach,  Apollinaris,  Kronthal). 


IV]        ABNORMAL   CONDITIONS   OF   URINE         49 

PHOSPHATURIA 

This  term  is  applied  to  the  presence  of  undissolved  earthy 
phosphates  in  the  urine.  The  phosphates  form  a  flocculent  deposit, 
or  the  urine  may  be  milky  and  deposit  a  thick  white  layer.  Occa- 
sionally in  a  clear,  well-coloured  urine  numerous  sparkling  crystals 
of  triple  phosphate  are  seen. 

Phosphoric  acid  to  the  extent  of  2-6  grm.  is  excreted  daily 
in  the  urine  in  the  form  of  phosphates  of  potassium,  sodium,  cal- 
cium, and  magnesium.  It  is  derived  largely  from  the  food,  but 
partly  from  the  tissues. 

The  acidity  of  the  urine  is  due  to  acid  phosphate  of  sodium. 
The  phosphates  of  lime  and  magnesium  are  only  soluble  in  acid 
urine,  and  when  the  urine  is  faintly  acid,  neutral,  or  alkaline  these 
salts  are  precipitated.  -When  the  alkalinity  is  due  to  ammonia 
from  decomposition  of  the  urine,  ammonio-magnesium  phosphate 
is  formed  and  is  deposited.  The  phosphatic  salts  of  sodium  and 
potassium,  which  form  about  two-thirds  of  the  total  phosphates, 
remain  in  solution,  whether  they  are  acid,  neutral,  or  basic. 

A  temporary  phosphaturia  occurs  after  a  meal  from  the  diges- 
tion of  food  rich  in  salts  of  vegetable  acids  or  alkaline  carbonates, 
and  partly  from  the  withdrawal  of  hydrochloric  acid  for  the  gastric 
secretion. 

Phosphaturia  is  sometimes  observed  in  children,  and  is  here  due 
to  an  increase  of  the  calcium  in  the  urine  and  deposit  of  calcium 
phosphate,  without  actual  increase  in  the  total  phosphatic  excre- 
tion. This  increased  calcium  output  in  the  urine  coincides  with 
a  diminution  in  the  calcium  in  the  faeces,  and  is  supposed  to  be 
due  to  an  inflammation  of  the  intestinal  mucosa.  This  phos- 
phaturia may  be  the  cause  of  scalding  during  micturition,  and 
increased  frequency  of  the  act. 

In  certain  individuals  of  a  nervous  type,  and  in  others  during 
a  period  of  nervous  strain,  a  copious  precipitate  of  earthy  phos- 
phates may  be  present,  so  that  the  urine  is  milky  when  passed. 
Nervous  dyspepsia  is  frequently  present,  and  is  said  to  cause  the 
phosphaturia.  The  total  daily  excretion  of  phosphates  is  not 
increased  in  these  cases.  The  phosphaturia  is  often  intermittent 
in  character,  and  occurs  after  a  period  of  unusual  anxiety.  I  have 
known  patients,  whose  urine  was  continuously  phosphatic  at  first, 
improve  under  treatment,  so  that  the  phosphaturia  appeared  only 
on  the  day  on  which  their  attendance  was  expected  at  hospital 
or  in  the  consulting-room.  These  patients  not  infrequently .  suffer 
from  intermittent  attacks  of  polyuria,  or  more  strictly  "  hydruria." 
I  have  met  with  a  patient  whose  urine  varied  in  the  course  of  one 


50  THE   KIDNEY  [chap. 

day  from  a  milky  phosphaturia  to  a  highly  acid  urine  which 
deposited  urates  on  cooling. 

Pronounced  phosphaturia  accompanied  by  dyspepsia  and  pro- 
longed intestinal  derangement  has  been  the  prelude  to  bacteriuria 
in  several  patients  under  my  observation. 

Patients  aiTected  with  this  type  of  phosphaturia  usually  com- 
plain of  symptoms  of  dyspepsia,  and  frequently  suffer  from  con- 
stipation. There  is  constant,  dull  aching  over  the  kidneys,  most 
marked  in  the  morning  on  rising.  The  urine  scalds  when  passed, 
and  there  is  a  feeling  of  dissatisfaction  after  micturition,  and  often 
some  increased  frequency  of  the  act.  The  urethral  mucosa  is 
reddened,  and  the  trigone  red  and  congested,  while  the  rest  of  the 
bladder  is  healthy  in  appearance.  Such  cases  usually  respond 
readily  to  treatment. 

A  more  serious  form  of  phosphaturia  has  been  called  "  'phos- 
fJiatic  diabetes.''^  In  this  there  is  an  actual  increase  in  the  quantity 
of  earthy  phosphates,  their  proportion  to  the  alkaline  phosphates 
being  as  much  as  5  to  2,  or  even  more,  instead  of  the  normal 
1  to  2.  The  quantity  of  urea  may  be  normal,  or  may  be  increased, 
though  in  a  less  proportion  than  the  earthy  phosphates.  The 
symptoms  consist  in  extreme  nervous  irritability,  dyspepsia,  and 
aching  pain  in  the  back  and  suprapubic  area.  There  are  increased 
frequency  of  micturition  and  scalding,  and  these  symptoms  may 
be  very  distressing.  Cystitis  is  caused  by  the  presence  of  masses  of 
phosphates  loosely  held  together  in  the  bladder.  There  is  no  de- 
composition of  the  urine,  which  is  neutral  or  faintly  alkaline  and 
non -bacterial.  Some  of  my  patients  have  dated  the  onset  of  their 
symptoms  from  the  day  on  which  they  entered  the  cold  atmosphere 
of  the  temperate  zone  on  returning  from  the  tropics.  There  may 
be  extreme  emaciation. 

With  a  tuberculous  heredity  such  cases  as  these  may  eventually 
develop  phthisis,  in  others  diabetes  mellitus  or  insipidus  has  fol- 
lowed. A  proportion  of  these  cases  recover  and  the  symptoms 
disappear.  In  many  patients  suffering  from  chronic,  posterior 
urethritis  a  slight  degree  of  phosphaturia  is  present,  and  varies  with 
the  changes  in  the  inflammation.  In  moderate  cystitis  without 
decomposition  of  the  urine,  phosphates  may  be  present  and  powder 
the  surface  of  the  bladder  mucous  membrane.  In  these  cases  the 
phosphaturia  is  probably  due  to  the  local  inflammation  further 
reducing  the  acidity  of  a  faintly  acid  urine.  Decomposition  of  the 
urine  with  liberation  of  ammonia  causes  a  deposit  of  ammonio- 
magnesium  phosphate  in  cases  of  severe  and  old-standing  cystitis, 
ulcers,  malignant  growths,  and  papilloma,  and  foreign  bodies  be- 
come encrusted  with  phosphatic  deposit. 


IV]  PHOSPHATURIA-BAGILLURIA  51 

Treatment. — Children  suffering  from  phosphaturia  should  sub- 
sist on  a  diet  poor  in  calcium  salts,  and  a  milk  diet  should  be  replaced 
by  one  consisting  partly  of  meat.  In  adults  the  slighter  cases  are 
treated  by  the  administration  of  tonics  and  mineral  acids,  such 
as  nitro-hydrochloric  acid  and  strychnine,  quinine,  phosphorus, 
and  cod-liver  oil.  Acid  phosphate  of  sodium  in  doses  of  10-20  gr. 
thrice  daily  speedily  cures  some  cases,  but  in  others  is  less  efficacious 
than  mineral  acids.  The  two  may  be  combined.  Where  the  phos- 
phaturia is  the  cause  of  severe  irritation  and  cystitis,  belladonna 
and  hyoscyamus,  and  occasionally  sandal- wood  oil,  are  useful. 
Opium  may  be  given  in  full  doses  in  the  same  forms  of  phospha- 
turia, but  should  hot  be  long  continued.  Alcohol,  coffee,  and  tea 
should  be  avoided.  Moderate  exercise  and  relief  from  worry  and 
anxiety  should  be  recommended.  Where  the  urine  is  decomposing 
the  treatment  is  that  of  chronic  cystitis.  Sodium  acid  phosphate 
is  especially  valuable  in  these  cases.  Its  use  for  increasing  the 
acidity  of  a  faintly  acid  urine,  or  for  rendering  an  alkaline  urine 
acid,  was  first  advocated  by  Dr.  Robert  Hutchison. 

BACTERIURIA— BACILLURIA 

Bacteriuria  or  bacilluria  is  a  condition  of  the  urine  in  which 
bacteria  are  present  in  such  abundance  that  they  render  the  fluid 
cloudy  to  the  naked  eye.  In  bacteriuria  inflammatory  products 
cannot  be  detected  by  the  naked  eye,  or  at  most  are  seen  in  very 
small  quantity.  It  is  also  a  characteristic  of  bacteriuria  that 
symptoms  of  inflammation  of  the  urinary  organs  are  either  absent 
or  very  slight. 

It  is  difficult  to  separate  some  cases  of  bacteriuria  from  cases 
of  infection  of  the  urinary  tract  where  there  is  excessive  bacterial 
growth  combined  with  definite  inflammatory  reaction. 

The  phenomenon  of  bacteriuria  represents,  however,  a  special 
type  of  urinary  infection  in  which  there  is  excessive  bacterial 
growth  and  minimal  reaction. 

Etiology. — Bacteriuria  is  found  in  infants  and  children,  as 
well  as  in  adults.     Women  are  more  frequently  affected  than  men. 

Pathology. — The  bacterium  coli  is  present  in  pure  culture  in 
over  80  per  cent,  of  cases.  It  is  frequently  atypical  in  its  cultural 
characters.  The  bacillus  of  typhoid  is  next  most  frequent.  The 
staphylococcus  albus  is  sometimes  present,  and  more  rarely  the 
proteus  vulgaris,  a  streptococcus,  or  the  bacillus  subtilis.  These 
bacteria  are  usually  present  in  pure  culture.  Bacteriuria  may  arise 
spontaneously,  or  it  may  supervene  in  the  course,  or  follow  in  the 
wake,  of  some  urinary  disease.  In  the  cases  which  are  spontaneous 
a  history  of  constipation,  diarrhoea,  or  indigestion  can  usually  be 


52  THE   KIDNEY  [chap. 

obtained,  and  in  several  cases  I  have  observed  pronounced  phos- 
phaturia  immediately  preceding  the  bacteriuria.  Other  predis- 
posing causes  are  chronic  septic  conditions  of  the  mouth  and  throat, 
operations  upon  the  rectum  and  anus,  and  boils  and  carbuncles. 
Typhoid  fever  precedes  the  form  known  as  typhoid  bacilluria,  and 
other  fevers  such  as  smallpox,  diphtheria,  scarlet  fever,  and  measles 
may  be  accompanied  by  bacteriuria.  The  bacillus  coli  is  frequently 
the  bacterium  present  in  the  urine  in  these  cases  of  bacteriuria 
associated  with  the  acute  fevers. 

Bacteriuria  may  supervene  during  the  course  of  a  subacute  or 
chronic  urethritis  of  the  prostatic  urethra,  or  a  chronic  prostatitis, 
or  chronic  seminal  vesiculitis.  It  may  immediately  follow  the 
passage  of  a  sound  or  catheter.  It  may  follow  an  acute  attack  of 
pyelitis,  and  I  have  observed  a  case  in  which  it  complicated  a 
movable  kidney  with  intermittent  hydronephrosis.  In  such  cases 
the  growth  of  bacteria  is  strictly  localized  to  the  diseased  area. 
In  a  prostatic  case  clear  sterile  urine  may  be  drawn  from  the  bladder, 
and  in  a  pyelitic  case  the  ureteric  catheter  demonstrates  that  the 
culture  ground  is  confined  to  the  renal  pelvis.  In  a  boy  with  stone 
in  the  ureter  whose  urine  was  previously  clear  and  sterile,  I  have 
seen  a  bacteriuria  suddenly  appear,  last  for  three  days,  and  then 
as  suddenly  disappear.  The  bacteria  gain  admission  to  the  urinary 
tract  through  the  kidneys  (haematogenous  infection),  or  are  intro- 
duced into  the  urethra  or  bladder  by  the  passage  of  instruments, 
or  may  be  deposited  at  the  urethral  opening  in  women  and 
female  children  and  ascend  to  the  bladder  (urinary  or  ascending 
infection). 

It  has  been  stated  that  the  bacteria  may  pass  directly  from 
the  rectum  through  the  rectal  and  bladder  walls,  but  of  this  there 
is  no  reliable  evidence. 

In  most  cases  of  hsematogenous  infection  the  bacteria  become 
implanted  in  some  part  of  the  urinary  tract,  and  continue  to  pro- 
liferate there ;  but  there  are  other  cases,  I  believe,  where  repeated 
infections  from  the  bowel  take  place,  the  bacteria  rapidly  dis- 
appearing after  each  infection. 

In  cases  of  uncomplicated  bacteriuria  post-mortem  examination 
has  failed  to  discover  any  lesion  of  the  mucous  membrane  of  the 
urinary  tract.  The  nidus  of  bacterial  growth  in  women  is  the 
renal  pelvis  in  the  great  majority  of  cases  ;  in  males  it  may  be  either ' 
the  renal  pelvis  or  the  prostate.  When  the  renal  pelvis  is  affected 
the  condition  is  frequently  unilateral. 

The  urine  is  hazy  when  passed,  from  the  suspension  of  myriads 
of  bacteria.  Frequently  an  opalescent  appearance  is  observed. 
On  rotating  a  glass  beaker  containing  the  urine,  so  as  to  circulate 


IV]  BAGILLURIA  53 

the  urine,  and  holding  it  to  the  light,  a  peculiar  appearance  is  seen, 
like  drifting  mist  or  smoke,  that  is  characteristic  of  the  condition. 
This  phenomenon  is  due  to  the  suspension  of  fine  particles  (the 
bacteria)  in  fluid.  It  is  to  be  seen  also  in  the  fluid  obtained  from 
a  spermatocele,  where  the  spermatozoa  form  the  suspended  particles. 
The  reaction  is  usually  acid,  occasionally  neutral,  and  rarely  alka- 
line. On  centrifuging  it,  no  deposit,  or  only  a  very  small  quantity 
of  deposit,  is  obtained,  and  the  fluid  remains  cloudy.  In  most 
cases  the  urine  has  a  peculiar  strong  fishy  odour.  It  is  never 
ammoniacal.  There  is  usually  a  trace  of  albumin,  and  protein 
can  be  detected  in  most  cases. 

Under  the  microscope  the  field  is  crowded  ^vith  bacteria,  usually 
the  motile  bacterium  coli.  A  few  leucocytes  may  be  found,  and 
epithelial  cells  from  the  renal  pelvis,  ureter,  and  bladder  or  prostatic 
urethra.  The  only  constant  sign  is  the  bacterial  emulsion  in  the 
urine.  The  urine  may  be  constantly  cloudy  for  months  or  years, 
or  it  may  clear  and  the  bacteria  disappear  with  almost  startling 
suddenness.  Just  as  suddenly  the  bacteria  may  reappear  in  as 
great  quantity  as  before.  I  have  seen  the  urine  milky  with  bac- 
terium coli  in  the  morning,  and  clear  in  the  afternoon  of  the 
same  day. 

There  may  be  no  symptoms  at  all,  but  signs  of  localized 
inflammation  are  seldom  entirely  absent. 

In  cases  of  chronic  prostatitis  or  posterior  urethritis  the  symp- 
toms of  these  diseases  are  already  present,  and  the  bacterial  con- 
dition of  the  urine  is  superadded.  In  bacteriuria  arising  without 
previous  urinary  disease  there  may  be  slight  increase  in  the  fre- 
quency of  micturition,  and  some  urgency  or  heat  and  burning  on 
passing  water.  These  symptoms  are  aggravated  by  cold  and  by 
dietary  indiscretions.  In  children,  nocturnal  enuresis  may  result 
from  bacteriuria.  Here  there  is  urgency  and  sometimes  frequent 
micturition  during  the  day ;  in  severe  cases  there  may  be  diurnal 
incontinence.  In  cases  where  the  prostatic  urethra  or  prostate  is 
the  seat  of  the  bacterial  growth  the  last  few  drops  of  urine  are 
often  milky  with  bacterial  emulsion,  while  the  rest  of  the  urine  is 
merely  hazy. 

In  other  cases  the  focus  of  bacterial  growth  is  confined  to  the 
renal  pehds.  If  the  bacteriuria  be  superadded  to  some  disease  the 
symptoms  of  that  disease  will  be  present.  In  cases  arising  spon- 
taneously there  may  be  some  aching  in  the  kidney  and  along  the 
course  of  the  ureter,  and  the  kidney  and  ureter  may  be  slightly 
tender.  There  are,  however,  cases  where  there  is  pronounced 
bacilluria  with  recm'rent  attacks  of  high  fever,  but  no  symptom 
referable  to  the  minary  organs  is  present. 


54  THE   KIDNEY  [chap. 

Prognosis. — In  some  cases  bacteriuria  is  transient  and  appears 
for  a  few  days  only,  disappearing  under  treatment.  It  may,  how- 
ever, be  more  persistent,  and  frequently  it  continues  with  exa- 
cerbations and  remissions  for  months  and  sometimes  for  years. 
During  this  time  the  condition  may  have  no  influence  on  the 
health  of  the  patient.  In  all  cases  there  is  the  danger  that  a  period 
of  lowered  resistance  from  some  other  cause  may  be  the  signal  for 
a  virulent  bacterial  inflammation  of  some  part  of  the  urinary  tract. 

Where  bacteriuria  is  superadded  to  some  disease  already  present, 
such  as  stone  in  the  ureter  or  movable  kidney,  it  is  the  precursor 
of  inflammatory  complications. 

Diagnosis. — The  diagnosis  is  made  by  the  observation  of  the 
characteristic  appearance  of  the  urine  and  bacteriological  examina- 
tion. It  is  imperative  to  ascertain  whether  the  bacilluria  is  the 
sole  condition  present,  or  whether  it  is  superadded  on  stone,  growth, 
chronic  inflammation,  or  other  pre-existing  disease.  Where  bacil- 
luria is  an  independent  condition  it  is  necessary  to  find  out  where 
the  focus  of  infection  has  commenced  (e.g.  appendix,  bowel),  and 
what  part  of  the  urinary  tract  is  affected  (e.g.  prostate,  renal 
pelvis).  The  latter  can  only  be  ascertained  by  examination  of  the 
prostate,  by  cystoscopy,  and  by  examination  of  the  urine  obtained 
from  each  kidney  by  the  ureteric  catheter. 

Treatment. — The  treatment  consists  in  the  administration  of 
urinary  antiseptics  and  diluents,  local  treatment  of  the  focus  of 
inflammation,  and  removal  of  the  source  of  bacterial  infection. 

Of  urinary  antiseptics  the  best  are  urotropine  (15-30  gr.  daily), 
oil  of  turpentine  (15-30  minims  daily)  in  capsules,  hetralin  or 
helmitol  (30  gr.  daily),  and  salol  (30  gr.  daily).  The  administration 
of  diuretics  and  alkaline  waters  with  these  antiseptics  appears  to 
render  the  urine  less  suitable  for  bacterial  growth.  Contrexeville, 
Vichy,  or  Evian  water  may  be  given,  or  the  patient  directed  to 
drink  large  quantities  of  distilled  or  barley  water. 

Rovsing  advises  that  in  bacterial  infection  of  the  urinary  tract 
a  catheter  should  be  retained  in  the  urethra  for  a  week  or  more 
while  salol  is  administered  by  the  mouth  and  large  quantities  of 
distilled  water  are  drunk. 

An  alternative  treatment  to  urinary  antiseptics  is  the  adminis- 
tration of  large  doses  of  alkalis  together  with  diuretics.  Citrate 
or  acetate  of  potash  (60-90  gr.  daily)  is  given  with  the  diuretic 
waters  already  mentioned. 

Where  the  focus  of  bacterial  growth  is  confined  to  the  prostatic 
urethra  and  bladder,  washing  the  bladder  and  urethra  by  Janet's 
irrigation  method  may  quickly  relieve  the  symptoms  and  suppress 
the  bacterial  growth.     The  solutions  suitable  for  this  irrigation  are 


IV]  BACILLURIA-H/EMATURIA  55 

permanganate  of  potash  (1  in  1(),()()0  to  1  in  5,000),  oxycyanide  of 
mercury  (1  in  10,000),  or  nitrate  of  silver  (1  in  10,000). 

When  the  bacterial  nidus  is  situated  in  the  renal  pelvis,  this 
may  in  some  cases  be  washed  with  weak  nitrate  of  silver  solution 
(1  in  10,000)  through  a  ureteric  catheter. 

It  is  of  the  utmost  importance  to  empty  the  bowel  and  prevent 
further  absorption.  A  mercurial  pill  followed  by  a  saline  purge 
should  be  given,  and  attention  paid  to  obtaining  a  regular  and 
free  action  of  the  bowel.  Small  doses  of  calomel  {j\—l  gr.)  may 
be  given  regularly  after  meals,  or  a  larger  dose  (1-2  gr.)  may  be 
given  once  a  week. 

In  order  to  reduce  the  growth  of  the  bacterium  coli  in  the 
intestine  a  course  of  milk  soured  with  the  Bulgarian  bacillus  (B. 
Caucasicum)  may  be  advised,  and  continued  for  several  months. 

Anti-coli  horse  serum  has  been  administered  with  some  success 
in  acute  cases  of  bacterium  coli  infection  of  the  urinary  tract,  and 
may  be  tried.  A  dose  of  25  c.c.  of  the  serum  should  be  injected 
subcutaneously  on  three  successive  days.  If  improvement  has 
not  taken  place  at  the  end  of  that  time  the  treatment  should  be 
abandoned.  Calcium  lactate  (20  gr.  thrice  daily)  should  be  admin- 
istered by  the  mouth  to  prevent  the  unpleasant  effects  of  the  serum. 

Treatment  by  vaccines  gives  varying  results.  In  some  cases 
the  bacteria  in  the  urine  rapidly  diminish  in  quantity,  and  in  a  few 
cases  disappear,  when  the  bacteriuria  has  been  uninfluenced  by 
other  methods  of  treatment.  In  cases  apparently  cured  by  vaccines 
recurrence  may  suddenly  take  place.  In  cases  treated  by  vaccines, 
and  also  in  those  treated  by  serum,  the  opsonic  index  of  the  blood 
may  rise  while  the  state  of  the  urine  remains  unchanged. 

Vaccines  should  be  prepared  from  cultures  taken  from  the 
patient's  urine.  In  bacterium  coli  infections  small  doses  of  vaccine 
up  to  10  or  15  millions  are  less  efficacious  than  higher  doses  from 
30  millions  and  upwards.  These  should  be  given  in  graduated 
series  up  to  100  millions,  or  even  higher,  at  intervals  of  a  week. 

Where  the  bacteriuria  is  superimposed  on  some  pre-existing 
disease  of  the  urinary  tract,  the  latter  must  be  suitably  dealt  with 
as  a  preliminary  to  treatment  of  the  bacilluria.  The  onset  of 
bacteriuria  in  a  case  of  movable  kidney  or  ureteric  calculus  should 
be  the  signal  for  operative  measures. 

HEMATURIA 

In  haematuria  the  amount  of  blood  in  the  urine  may  be  so 
small  that  the  microscope  is  required  for  its  detection,  or  there 
may  be  so  great  a  quantity  that  the  fluid  appears  to  consist  wholly 
of  blood. 


56  THE   KIDNEY  [chap. 

An  appearance  resembling  blood  is  given  to  the  urine  in  hsemo- 
globinuria,  and  after  the  ingestion  of  some  drugs,  such  as  senna, 
rhubarb,  sulphonal,  etc.  The  final  test  for  hsematuria  is  the  dis- 
covery of  red  blood-corpuscles  by  the  microscope.  The  urine  in 
hsemoglobinuria  has  a  peculiar  purple  colour ;  it  contains  no 
clots,  and  there  are  no  blood  corpuscles  even  after  centrifugalizing. 
Heematuria  may  take  origin  in  any  part  of  the  urinary  tract, 
and  may  be  caused  by  a  large  number  of  surgical  diseases.  In 
examining  a  case  of  heematuria  it  is  necessary  first  to  localize  the 
bleeding  to  one  part  of  the  urinary  tract,  and  then  to  diagnose 
the  disease  which  causes  it. 

1.  Localization  of  hpematuria. — The  discharge  of  blood  from 
the  meatus,  apart  from  micturition,  will  indicate  that  the  source 
of  haemorrhage  is  anterior  to  the  compressor  urethrse  muscle.  At 
any  part  of  the  urinary  tract  behind  the  compressor  urethree  blood 
will  mix  with  the  urine  and  will  only  be  discharged  with  it. 

RcBmaturia  with  other  symptoms. — Hsematuria  may  be  the  solitary 
symptom,  or  it  may  be  accompanied  by  other  symptoms  which 
indicate  the  source  of  the  haemorrhage. 

Heematuria  with  fain. — Severe  pain  in  one  kidney  and  ureteric 
colic  will  localize  the  haemorrhage  to  this  kidney,  the  renal  pelvis, 
or  the  ureter.  Dull  aching  in  one  kidney  is  not  so  reliable  a  symp- 
tom. A  papilloma  or  malignant  growth  of  the  bladder  at  one  ure- 
teric orifice  may  give  rise  to  hsematuria  with  unilateral  renal  aching. 

Pain  at  the  end  of  the  penis  on  micturition  points  to  the  base 
of  the  bladder  or  the  prostatic  urethra  as  the  source  of  the  blood ; 
while  pain  at  the  base  of  the  sacrum,  in  the  rectum  or  perineum, 
will  point  to  the  prostate. 

Hwmaturia  with  frequent  micturition. — Frequent  micturition 
suggests  the  localization  of  the  point  of  haemorrhage  to  the  prostatic 
urethra  or  bladder.  Copious  bleeding  which  has  come  from  the 
kidney  may,  however,  cause  irritation  of  the  bladder,  and  this  is 
more  likely  when  clots  are  present  in  the  urine. 

In  some  diseases  of  the  kidney,  such  as  tuberculosis,  reflex 
irritation  of  the  bladder  is  a  prominent  feature.  It  follows  that 
haematuria  with  frequent  micturition  may  be  caused  by  disease 
of  the  kidney  when  the  bladder  is  healthy. 

Heematuria  with  obstruction. — Urethral  obstruction  may  be 
temporarily  produced  by  the  impaction  of  a  clot  in  the  urethra, 
but  the  combination  of  obstruction  and  haematuria  is  most  fre- 
quently due  to  prostatic  or  urethral  disease, 

A  papilloma  of  the  bladder  situated  near  the  internal  meatus, 
or  one  provided  with  a  long  pedicle,  may  cause  haematuria  with 
attacks  of  obstruction. 


IV]  Hv^MATURIA  57 

Examination  of  the  urine. — The  colour  of  the  urine  may  be 
of  some  assistance.  The  longer  the  blood  remains  in  contact  with 
the  urine  the  more  likely  is  it  to  be  discoloured.  The  higher  the 
source  of  blood  in  the  urinary  tract  the  more  likely  is  it  to  be  well 
mixed  with  the  urine.  Blood  in  a  highly  acid  urine  is  brownish 
in  colour,  and  in  an  alkaUne  urine  bright  red.  When  much  pus 
is  mixed  with  the  blood,  and  the  urine  is  decomposing,  a  dirty- 
brownish,  muddy  appearance  is  given  to  the  urine. 

The  urine  may  have  a  brownish  or  smoky  appearance.  This 
indicates  that  the  blood  is  small  in  quantity,  well  mixed  with  the 
urine,  and  the  reaction  acid.  Such  bleeding  is  usually  renal  in 
origin.  In  renal  hsematuria  the  blood  precipitates  very  slowly,  so 
that  a  sediment  forms  only  after  several  hours.  In  coffee-coloured 
urine  the  source  of  bleeding  is  frequently  the  kidney  or  kidney 
pelvis,  but  the  blood-  may  come  from  the  bladder  or  prostate, 
especially  if  there  be  urethral  obstruction.  Purple  urine  denotes 
venous  bleeding,  which  may  be  derived  from  any  part  of  the  urinary 
tract. 

If  the  urine  has  a  dehcate  pink  colour  the  blood  usually  comes 
from  the  bladder  or  the  prostatic  urethra.  Bright-red  blood 
indicates  copious  bleeding  from  an  arterial  source,  and  may  be 
discharged  from  any  part  of  the  urinary  tract.  Disease  of  the 
bladder  or  prostate  is  the  most  frequent  cause  of  such  bleeding. 

Tyye  of  hcematuria. — The  blood  may  be  present  at  the  beginning 
or  at  the  end  of  micturition,  or  thoroughly  mixed  with  the  urine. 
Blood  appearmg  at  the  beginning  of  micturition  (initial  hsematuria) 
has  a  urethral  origin,  and  usually  comes  from  the  prostatic  urethra. 
Terminal  hsematmia  may  mean  that  the  first  urine  is  clear  and 
blood  appears  at  the  end  of  micturition,  or  that  the  earlier  part  of 
the  stream  is  blood-stained  and  the  last  part  pure  blood.  The 
blood  in  this  type  is  derived  from  the  prostatic  urethra  or  the 
bladder.  No  inference  can  be  drawn  as  to  the  source  of  blood 
which  is  mixed  with  the  whole  of  the  urine  (total  haematuria). 

Presence  of  clots. — The  formation  of  clots  depends  largely  upon 
the  proportion  of  blood  in  the  urine.  Blood  poured  out  in  large 
quantities  from  the  kidney  or  renal  pelvis  may  clot  in  the  ureter. 
Slender  worm-like  clots,  10  or  12  in.  in  length,  are  sometimes 
passed  in  such  cases,  and  are  diagnostic  of  the  source  of  the 
bleeding.  More  frequently,  however,  the  clots  passed  from  the 
ureter  are  small  plugs,  |  in.  in  length.  The  blood  may  be  rapidly 
passed  into  the  bladder  and  clot,  there  forming  irregular  masses 
or  flat  clots  which  indicate  the  position  of  the  clotting  but  not 
the  source  of  the  hsemorrhage.  Vesical  hsemorrhage  vdW  produce 
these  flat  or  irregular  clots.     Urethral  bleeding  may  form  a  clot 


58  THE   KIDNEY  [chap. 

which  lies  in  the  urethra  and  is  discharged  with  the  urine.  This 
will  form  a  long  worm-like  clot,  not  unlike  that  derived  from  the 
ureter,  but  it  is  thicker  and  shorter,  and  frequently  shows  en- 
largements and  contractions  corresponding  to  the  varying  calibre 
of  the  urethra. 

Albumin  can  be  demonstrated  in  the  urine  in  haematuria,  even 
where  the  amount  of  blood  is  very  small.  In  cases  of  renal  hsema- 
turia,  however,  the  quantity  of  albumin  is  in  excess  of  what  might 
be  expected  to  be  present  from  the  admixture  of  blood.  If  on 
estimation  the  proportion  of  albumin  to  haemoglobin  prove  to  be 
more  than  1*6  to  1,  this  points  to  a  renal  affection  as  the  cause  of 
the  hsematuria  (Newman). 

In  renal  hsematuria  the  corpuscles  often  appear  as  pale  discs, 
almost  devoid  of  colouring  matter,  while  the  corpuscles  that  are 
added  to  the  urine  in  the  lower  urinary  tract  are  less  changed. 

Epithelial  and  other  elements  may  be  found  in  the  urine,  and 
give  an  indication  of  the  source  of  the  bleeding. 

Casts  of  the  renal  tubules,  if  present,  indicate  a  renal  source  of 
the  hsematuria.  Epithelial  cells  from  the  kidney,  pelvis  and  ureter, 
bladder  or  urethra,  may  be  discovered  and  help  to  localize  the 
source  of  the  haemorrhage. 

Examination  of  the  patient. — This  may  reveal  signs  of  dis- 
ease which  point  to  the  source  of  bleeding.  The  kidneys,  ureters, 
and  bladder  should  be  examined  by  abdominal  palpation,  and  the 
prostatic  and  membranous  urethra,  the  prostate,  seminal  vesicles, 
bladder  base,  and  lower  ureters  examined  from  the  rectum. 

Cystoscopic  examination. — The  cystoscope  is  the  means  by 
which  the  source  of  the  hsematuria  can  be  localized  with  certainty. 
On  cystoscopy,  some  disease  of  the  bladder,  such  as  papilloma, 
may  be  discovered  ;  or  the  bladder  may  be  found  healthy,  and  the 
hsematuria  will  be  known  to  originate  in  the  kidney,  or  kidney 
pelvis.  On  examining  the  ureteric  orifices,  changes  may  be  observed, 
such  as  ulceration  or  tuberculous  deposit,  which  will  assist  in  the 
localization  of  the  haematuria.  Where  no  gross  changes  are  present 
at  the  ureteric  orifices  there  is  sometimes  a  slight  staining  of  the 
lips  of  the  orifice  on  the  side  whence  the  hsematuria  is  proceeding. 
Examination  of  the  efflux  from  the  ureters  may  show  blood-stained 
urine  issuing  from  one  or  both  sides.  (Plate  5,  Fig.  1.)  When  the 
quantity  of  blood  is  small  it  may  be  extremely  difficult  to  detect 
any  change  in  the  efflux.  The  haematuria  may  sometimes  cease 
suddenly  before  the  cystoscopy,  so  that  the  examination  must  be 
repeated.  Finally,  the  ureters  should  be  catheterized  and  a  sample 
of  urine  obtained  from  each  kidney  for  microscopical  examination. 
This  examination  should  only  be  carried  out  by  an  expert,  for  the- 


Fig.  1. — Heematuria.  Blood-stained  efflux 
from  left  ureter.     (P.   58.) 

Fig.  2. — Semi-solid  pus  issuing  from 
ureter  in  case  of  chronic  sup- 
purative pyelonephritis.  Acute 
cystitis.     (Pp.  65,  125.) 


Plate  5. 


IV]  ESSENTL4L  RENAL  H/EMATURIA  59 

technique  is  difficult,  and  bleeding  is  easily  produced  in  passing  the 
ureteric  catheter,  and  thus  the  object  of  the  examination  is  Ukely 
to  be  defeated. 

2.  Diagnosis  of  the  cause  of  haematuria. — Haematuria  may 

appear  in  almost  any  disease  of  the  urinary  organs. 

The  character  of  the  haematuria  and  the  position  it  occupies 
in  the  symptomatology  of  each  disease  will  be  fittingly  described 
under  the  various  diseases.  There  is,  however,  one  form  of  haema- 
turia which  cannot  be  referred  to  any  single  disease,  and  it  must 
therefore  be  dealt  with  in  this  place. 

Essential  renal  hsematuria. — This  name  has  been  given  to  a 
group  of  cases  in  which  hsematuria  has  been  localized  to  one  kidney, 
and  nephrotomy,  with,  in  some  cases,  an  examination  of  the  kidney 
after  removal,  has  failed  to  reveal  the  cause  of  the  haemorrhage. 
More  careful  examination  of  these  kidneys,  however,  shows  that 
in  most  of  them  a  partial  chronic  nephritis  exists,  and  in  a  few 
there  is  a  varicose  condition  of  one  or  more  of  the  renal  papillae. 
The  partial  chronic  nephritis  which  is  present  in  these  cases  gives 
rise  to  no  changes  visible  to  the  naked  eye,  so  that  the  condition 
is  readily  overlooked  when  the  kidney  is  examined  by  nephrotomy. 
Further,  it  is  not  found  in  every  microscopic  section  of  the  kidney 
substance,  so  that  it  may  be  overlooked  unless  careful  search  be 
made  in  a  number  of  such  sections. 

In  sC  section  of  the  renal  cortex  the  tubules  and  glomeruh  are 
normal  in  appearance,  except  at  one  part  where  there  is  a  patch 
of  fibrous  tissue  separating  the  renal  tubules.  The  fibrous  tissue 
may  be  poor  in  nuclei,  or  there  may  be  an  abundant  infiltration  of 
small  round  cells.  Frequently  the  fibrous  tissue  forms  a  streak 
radiating  towards  the  capsule ;  occasionally  it  is  subcapsular. 
The  capsule  is  frequently  thickened,  and  there  may  be  a  patch  of 
thickening  at  the  spot  where  an  intertubular  streak  of  fibrous 
tissue  reaches  the  surface  of  the  kidney.  One  or  several  completely 
sclerosed  and  atrophied  glomeruli  may  be  seen ;  sometimes  there 
is  only  a  thickening  of  the  capsule  of  Bowman.  The  walls  of  the 
vessels  do  not  appear  changed,  but  occasionally  I  have  found  the 
veins  dilated,  and  there  may  be  some  perivascular  infiltration  of 
round  cells.  The  tubules  are  frequently  found  filled  with  blood. 
The  epithelium  of  the  kidney  is  unchanged.  A  few  cases  have  been 
recorded  in  which  haematuria  without  other  symptoms  and  without 
albuminuria  has  been  caused  by  a  more  extensive  unilateral  chronic 
nephritis  (Poirier,  Loumeau). 

The  characters  of  essential  renal  haematuria  are  as  follows  : 
It  is  spontaneous,  and  no  cause  can  be  assigned  for  the  onset ;  it 
is  not  afiected  bv  rest  or  movement.     The  blood  is  abundant  and 


60  THE   KIDNEY  [chap. 

well  mixed,  and  the  urine  has  a  dark  port-wine  colour.  Clots  are 
very  rarely  formed.  The  heematuria  is  strictly  unilateral ;  it  may 
suddenly  cease  after  some  weeks  or  months,  and  may  as  suddenly 
reappear  and  become  persistent.  In  the  intervals  of  clear  urine 
no  albumin  can  be  detected  and  no  tube  casts  found.  No  bacteria 
are  found  in  the  urine.  There  is  occasionally  a  dull  aching  pain 
on  the  side  from  which  the  hsematuria  proceeds :  this  is  unaffected 
by  movement.     The  kidney  is  not  tender  or  enlarged. 

In  thirteen  cases  of  unilateral  symptomless  hsematuria  in  which 
I  explored  the  kidney  and  removed  a  portion  for  examination  the 
microscope  showed  patches  of  fibrosis  of  varying  size  in  the  cortex 
in  all.  The  capsule  was  frequently  thickened,  solitary  sclerosed 
glomeruli  were  sometimes  found,  and  there  was  blood  in  the  con- 
voluted tubules  in  seven  cases.  It  is  possible  that  the  cause  of 
these  changes  may  be  the  excretion  of  bacteria  by  the  kidneys  in 
constipation  and  other  conditions  {see  p.  120). 

A  varicose  condition  of  one  or  more  of  the  renal  papillae  has 
been  described  by  Fenwick  and  by  Whitney  and  Pilcher.  The 
origin  of  this  varicose  condition  appears  to  be  doubtful,  and  it 
may  possibly  result  from  a  patch  of  interstitial  nephritis  similar  to 
the  condition  described  above.  The  type  of  haematuria  and  absence 
of  other  symptoms  are  similar. 

Profuse  unilateral  renal  hsematuria  which  is  unaccompanied  by 
other  symptoms  is  sometimes  met  with  as  a  premonitory  or  early 
symptom  of  chronic  Bright's  disease.  Roy,  Harmonic,  and  Israel 
have  described  cases  in  which  the  symptoms  of  chronic  Bright's 
disease  developed  several  years  after  a  spontaneous,  symptomless 
hsematuria.  Newman  has  recorded  a  case  of  severe  renal  hsematuria 
which  preceded  other  symptoms  of  tubercular  disease  by  two  years. 
"  Symptomless  "  hsematuria  is  a  symptom  of  some  growths  of  the 
kidney  from  a  very  early  stage  of  their  development. 

Treatment  of  essential  hsennaturia. — Exploration  of  the 
kidney  by  operation  is  necessary  in  such  cases  of  unilateral  hsema- 
turia. If  a  papilla  of  the  kidney  shows  congestion  it  may  be 
cut  away  with  a  sharp  spoon.  Where  no  such  appearance  is 
observed  and  nephrotomy  fails  to  discover  any  lesion  in  the  sub- 
stance of  the  kidney,  the  wounds  in  the  kidney  and  renal  pelvis 
should  be  closed  with  catgut  sutures.  The  hsematuria  in  the 
majority  of  cases  ceases  after  the  exploration,  apparently  as  a 
result  of  pressure  upon  the  bleeding  vessel  by  the  sutures.  For 
this  reason,  and  also  because  bilateral  nephritis  may  give  rise  to 
unilateral  hsematuria,  nephrectomy  should  not  be  performed.  Very 
rarely  haemorrhage  commences  again  and  necessitates  a  second 
operation. 


IV]  H/EMATURIA:   TREATMENT  61 

Hale  White  describes  five  cases  of  renal  hsematuria  in  wKich  the 
kidney  was  explored  by  nephrotomy  and  no  lesion  found.  Two  of 
these  cases  had  a  recurrence  of  haemorrhage,  in  three  there  was  none. 

Decapsulation  may  be  combined  with  nephrotomy,  but  the 
results  are  similar  to  those  of  nephrotomy  alone,  the  haematuria 
recurring  in  rare  cases. 

Treatment  of  hzematuria. — It  is  only  in  exceptional  cases 
that  treatment  of  haematuria  apart  from  operative  measures  is 
required.  The  following  drugs  may  be  used,  viz.  morphia,  ergot, 
ergotine,  tincture  of  hamamelis,  and  calcium  chloride  or  lactate.  Of 
these,  morphia  and  calcium  lactate  are  the  best.  A  hypodermic 
injection  of  morphia  is  given,  and  the  patient  placed  on  calcium 
lactate,  10  gr.  in  cachets  being  given  every  four  hours  for  forty-eight 
hours.     After  this  period  the  calcium  lactate  should  be  omitted. 

Local  treatment. ^In  renal  hsematuria,  dry  cupping  over  the 
loin,  and  icebags  over  the  kidney,  may  be  employed.  Adrenahn  has 
been  injected  into  the  renal  pelvis  through  a  ureteric  catheter, 
1  drachm  of  a  l-in-5,000  solution  being  used. 

Vesical  haematuria. — A  catheter  should  be  passed  and  the 
bladder  washed  out  with  hot  boric  solution,  or  with  a  hot,  very 
weak  solution  (1  in  15,000)  of  silver  nitrate.  Large  quantities  of 
these  solutions  must  be  used,  the  stream  being  supplied  from  an 
irrigatoi'  or  a  large  glass  hand-syringe.  A  double-way  catheter 
with  continuous  irrigation  is  often  useful. 

After  washing  the  bladder,  10-12  oz.  of  a  solution  of  antipjrrin 
(10  per  cent.)  are  introduced  and  left  in  for  a  few  minutes,  or  1 
or  2  drachms  of  adrenahn  solution  (1  in  2,000)  are  injected  into 
the  bladder,  left  for  a  few  minutes,  and  then  run  out.  If  clots 
are  present  in  the  bladder  they  may  be  washed  out  through  a  large 
catheter,  or,  better,  through  a  large  evacuating  catheter  such  as 
is  used  in  lithotrity.  The  rubber  lithotrity  bulb  may  be  attached 
and  the  clots  sucked  out. 

1)  These  methods  should ^not  be  persisted  in  for  long,  and,  if  the 
clots  are  of  large  size  and  the  bladder  has  become  distended  with 
them,  suprapubic  cystotomy  should  be  performed,  the  clots  cleared 
out,  and  a  stream  of  hot  boric  solution  (115°  to  120°  F.)  passed 
through  a  catheter  in  the  urethra,  and  allowed  to  well  out  of 
the  suprapubic  opening.  A  large  drainage  tube  (1  in.  diameter) 
should  then  be  placed  in  the  bladder,  and  the  foot  of  the  bed 
raised  on  blocks. 

LITERATURE 

Albarran,  Prcssc  Med.,  1904,  p.  657. 
Fenwick,  Clinical  Cystoscopy.     London,  1904, 
Graff,  Folia   Urol.,  1908,  p.  274. 


62  THE   KIDNEY  [chap. 

LITERATURE— co7itinued 

Israel,  Deuts.  med.   Woch.,  Feb.  27,  1902 ; 

Mittheil.  aus  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1899,  p.  471. 
Klotzenberg,  Zeits.  /.  Urol.,  1908,  p.  125. 
Kretschner,  Zeits.  f.   Urol.,  1907,  S.  490. 
Legueu,   Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1891,  p.  564. 
Pilcher,   Ann.  Surg.,  1909,  p.  652. 
Rovsing,  Brit.  Med.  Journ.,  1898,  ii.  1547. 
White,  Hale,  Quart.  Journ.  Med.,  1911,  p.  509. 
Whitney,  Boston  Med.  Surg.  Journ.,  1908,  p.  797. 

PYURIA 

The  presence  of  pus  in  the  urine  is,  except  in  a  few  rare  cases, 
a  sign  of  inflammation  of  some  part  of  the  urinary  tract.  The 
inflammation  may  be  confined  to  one  segment  of  the  urinary  tract, 
such  as  the  urethra,  the  bladder,  or  the  renal  pelvis,  or  it  may  be 
more  widely  spread,  and  affect  the  bladder  and  pelvis  of  the  kidney. 
While  pyuria  is  always  due  to  inflammation,  the  ultimate  cause 
of  the  inflammation  varies.  There  may  be  a  bacterial  infection 
of  an  otherwise  healthy  urinary  tract,  or  there  may  be  bacterial 
infection  superadded  to  stone,  stricture,  growths,  or  other  gross 
lesions.  Further,  one  bacterial  inflammation  may  be  superimposed 
or  follow  upon  another  of  a  different  character :  thus,  a  staphylo- 
coccal or  streptococcal  inflammation  may  be  added  to  a  tuber- 
culous inflammation.  It  is  necessary  to  localize  the  origin  of  the 
pus  as  a  preliminary  to  making  a  diagnosis  of  the  cause. 

1.  Examination  of  the  urine,  {a)  Quantity. — Apart  from 
acute  inflammation  of  the  urethra,  the  distribution  of  which  will 
be  evident  from  the  discharge  of  pus  at  the  meatus,  the  largest 
quantities  of  pus  are  derived  from  purulent  collections  in  the 
kidney.  In  cases  of  long-standing  bladder  inflammation  the 
quantity  of  deposit  may  be  large,  but  the  proportion  of  pus  is 
not  so  great. 

(6)  Character  of  the  pus. — Pus  in  small  quantities  makes  the 
urine  cloudy  and  opaque,  and  in  large  quantities  milky.  This 
may  be  equally  produced  by  a  copious  urethral  discharge  and  a 
pyelonephritis,  but  the  clinical  features  of  the  cases  are  so  obviously 
different  that  no  question  of  differential  diagnosis  need  arise. 
Pus  from  the  urethra  is  mixed  with  a  certain  amount  of  mucus, 
so  that  the  deposit,  which  settles  quickly  to  the  bottom  of  the  glass, 
has  a  fluffy,  feathery  appearance.  The  urine  in  inflammation  of 
the  bladder  gives  a  deposit  which  is  billowy  and  fluffy,  and  occupies 
a  large  part  of  the  glass  without  sinking  heavily  to  the  bottom. 
The  urine  is  generally  high-coloured  and  has  a  high  specific  gravity. 
In  severe  grades  of  old-standing  cystitis  the  urine  may  be  like  coffee 
to  which  a  large  proportion  of  milk  has  been  added.     The  sedi- 


IV]  PYURIA  63 

ment,  after  standing  for  an  hour  or  two,  is  thickly  viscous,  and 
clings  like  slime  to  the  bottom  of  the  vessel. 

Renal  pus — that  is,  pus  which  is  produced  in  the  renal  pelvis 
or  in  a  dilated  kidney — gives  a  milky  urine  when  passed,  and  a 
characteristic  deposit  on  standing.  A  heavy  solid  layer  of  yellow 
or  yellowish-green  pus  with  a  flat,  even  surface  lies  at  the  bottom 
of  the  vessel  and  rolls  heavily  to  the  lowest  part  when  the  vessel 
is  canted.  The  supernatant  fluid  is  cloudy  with  suspended  pus 
or  bacteria.  The  urine  is  usually  pale  in  colour  and  of  low  specific 
gravity.  When  a  suppurative  renal  disease  is  combined  with 
cystitis,  there  is  the  solid  layer  of  pus  at  the  bottom  of  the  glass, 
and  above  this  is  a  layer  of  billowy,  fluffy  muco-pus. 

(c)  Odour  and  reaction  of  the  urine. — There  is  no  unusual 
odour  in  the  pyuria  of  a  purulent  urethritis.  In  bacteriuria,  when 
the  bacterial  growth  is  excessive  and  the  pyuria  in  minimal  amount, 
the  odour  of  the  urine  is  "  fishy." 

In  chronic  cystitis  the  urine  becomes  decomposed  and  has  a 
pungent,  ammoniacal  odour.  As  a  rule,  purulent  urine  from  the 
kidney  has  no  strong  or  characteristic  odour,  but  a  purulent  col- 
lection in  a  dilated  kidney  may  be  offensive,  and  a  pyelitis  mth 
excessive  bacterial  growth  may  possess  a  very  strong,  penetrating 
smell. 

That  "  acid  pyuria  is  from  the  kidney  and  alkaline  pyuria  from 
the  bladder "  is  no  longer  accepted  as  accurate.  The  following 
bacteria  produce  acute  cystitis  in  which  the  purulent  urine  remains 
acid,  viz.  the  bacillus  coh,  gonococcus,  and  bacillus  typhosus ; 
while  the  tubercle  bacillus  produces  a  subacute  or  chronic  cystitis 
Avith  an  acid  urine.  The  bacillus  coli  is  the  most  frequent  cause 
of  cystitis.  The  staphylococcus,  streptococcus,  and  proteus  are 
the  bacteria  of  alkaline  cystitis.  These  bacteria  cause  the  ammo- 
niacal decomposition  of  the  urine  found  in  chronic  non-tuberculous 
cystitis. 

The  pyuria  of  pyelitis  is  usually  acid,  but  not  invariablv  so. 
Ammoniacal  decomposition  may  take  place  from  the  same  causes 
as  in  the  bladder.  A  slightly  alkaline  urine  from  the  kidney  is 
mixed  with  the  acid  urine  from  the  second  kidney,  and  the  blended 
urine  is  acid.  Catheterization  of  the  ureters  separates  the  alkaline 
and  acid  urines  in  these  cases. 

(d)  Type  of  pyuria. — The  urine  should  be  passed  into  two 
glasses.  Pus  appearing  at  the  begimiing  of  micturition  has  a 
urethral  origin.  When  the  urine  is  clear  at  the  beginning  of 
micturition  and  purulent  at  the  finish,  the  pus  comes  from  the 
prostate  or  bladder. 

Intermittent  pyuria  is  the  special  characteristic  of  the  discharge 


64  THE   KIDNEY  [chap. 

from  an  inflamed  dilated  renal  pelvis.  The  urine  is  clear,  or  almost 
clear,  for  days  or  weeks,  and  during  this  time  renal  symptoms  are 
present  and  increase  in  severity.  Then  the  urine  suddenly  becomes 
thick  with  pus  and  the  renal  symptoms  disappear.  This  is  repeated 
at  varying  intervals.  Intermittent  pyuria  may  also  be  observed 
when  an  abscess  sac  repeatedly  discharges  into  the  bladder  or 
urethra,  or  there  is  a  diverticulum  of  the  bladder  which  has  become 
infected. 

(e)  Chemical  and  microscopicai  character  of  the  urine. — 
Albumin  is  present  in  pyuria  in  a  small  amount,  which  is  pro- 
portional to  the  quantity  of  pus  present.  When  nephritis  is  pre- 
sent, as  in  pyelonephritis,  the  quantity  of  albumin  is  greater.  In 
catarrhal  pyelonephritis  the  albumin  will  only  give  a  cloud,  while 
in  suppurative  pyelonephritis  it  may  be  present  in  large  quantity. 

If  the  albumin  appears  to  be  present  in  excessive  quantities, 
renal  complication  may  be  suspected.  The  proportion  of  albumin 
to  the  number  of  pus  corpuscles  per  cubic  millimetre  may  assist 
the  diagnosis.  The  albumin  should  bear  the  relation  of  1  in 
1,000  when  the  pus  corpuscles  number  100,000  per  c.mm.  In  a 
urine  which  contains  40,000  per  c.mm.  and  shows  2  per  1,000  of 
albumin,  the  albumin  must  be  derived  from  another  source  than 
the  pus.  Epithelial  elements  may  be  present  in  the  urine,  but 
have  rather  less  significance  in  regard  to  localization  here  than 
in  hsematuria.  Tube  casts  are  found  in  the  slighter  forms  of 
pyelonephritis,  and  are  of  importance  in  localizing  the  process 
where  symptoms  are  absent  or  slight. 

2.  Presence  of  localizing  symptoms. — The  symptoms  of 
prostatic  disease  and  disease  of  the  seminal  vesicles,  and  rectal 
examination,  will  clearly  distinguish  pyuria  which  proceeds  from 
these  organs  from  that  derived  from  the  bladder  and  kidneys. 
In  these  cases  clear  urine  may  be  drawn  by  catheter  from  the 
bladder,  while  the  urine  which  is  passed  is  purulent.  The  symp- 
toms of  inflammation  of  the  bladder  will  demonstrate  that  that 
organ  is  diseased,  but  the  cystitis  may  be  produced  by  secondary 
infection  of  the  bladder  from  the  kidney  by  way  of  the  ureter,  or 
there  may  be  reflex  bladder  symptoms  from  the  kidney  without 
actual  vesical  disease.  The  renal  symptoms  in  these  cases  are 
frequently  minimal,  while  the  bladcler  symptoms  are  prominent. 

3.  Other  methods  of  examination,  {a)  Cystoscopy. — The 
cystoscope  is  a  means  of  localizing  disease  causing  pyuria  in  a 
large  number  of  cases  which  would  otherwise  remain  obscure. 
When  the  cause  of  the  pyuria  lies  in  the  bladder  the  disease  will 
be  diagnosed  at  the  same  time.  When  the  kidney  is  at  fault  the 
source  of  the  pyuria  will  be  localized  to  one  or  both  organs. 


IV]  PYURIA— GHYLURIA  65 

The  examination  of  the  ureteric  orifices  should  not  be  neglected, 
even  when  all  the  symptoms  point  to  cystitis  and  the  cystoscope 
lends  support  to  the  view. 

Disease  of  the  bladder  exclusively  surrounding  one  ureteric 
orifice,  changes  at  the  orifice  itself,  and  the  observation  of  murky 
or  purulent^  urine  coming  from  one  ureter  will  show  that  there  is 
disease  of  the  kidney,  whether  renal  symptoms  are  present  or 
not.  When  the  quantity  of  pus  in  the  urine  is  small  and  the  bladder 
inflamed,  it  may  be  very  difficult  to  distinguish  the  pyuria  by  exam- 
ining the  ureteric  efflux.  In  such  cases  catheterization  of  the  ureters 
will  become  necessary.  A  urine  with  a  moderate  quantity  of  pus 
and  shreds  is  readily  distinguished  as  purulent  at  the  ureteric 
orifice  ;  when  the  pus  is  present  in  quantity  the  appearance  of 
the  efflux  is  unmistakable.  Pipes  of  semi-sohd  pus  are  observed 
issuing  from  the  ureteric  orifice  in  some  cases  of  advanced  sup- 
purative disease  of  the  kidney.     (Plate  5,  Fig.  2.) 

(6)  Catheterization  of  the  ureters. ^When  cystitis  is  pre- 
sent, catheterization  of  the  ureters  may  be  difficult.  A  general 
anaesthetic  will  be  required,  and  a  good  deal  of  patience  must  be 
exercised.  The  various  forms  of  separator  are  quite  unsuitable 
for  use  in  such  cases.  The  urine  collected  from  each  ureter  is  com- 
pared, each  urine  is  examined  microscopically  and  chemically, 
and  cultures  are  made.  Very  important  information  may  thus  be 
gained  which  cannot  be  obtained  by  other  methods.  In  a  case 
of  chronic  cystitis  it  may  be  possible  to  show  by  this  means  that 
purulent  urine  comes  from  one  kidney  and  contains  tubercle 
or  colon  bacilli,  while  the  urine  collected  from  the  other  ureter 
is  healthy. 

(c)  Radiography. — In  cases  of  long-standing  pyuria  radio- 
graphy may  show  the  presence  of  stones  in  one  or  both  kidneys 
when  no  symptom  of  their  presence  has  been  observed. 

CHYLURIA 

In  chyluria  there  is  fat  in  emulsion  in  the  urine  so  finely 
divided  that  no  globules  of  fat  are  found  with  the  microscope. 
The  urine  is  milky,  and  on  standing  a  layer  like  cream  separates 
and  rises  to  the  surface.  Shaking  with  ether  extracts  the  fat  and 
clears  the  urine.  The  condition  is  found  in  filariasis,  in  which  the 
lymphatics  are  blocked  with  the  filaria  worms  above  the  entrance 
of  the  lacteals.  The  obstruction  causes  dilatation  of  the  lymphatics 
of  the  renal  pelvis,  ureter,  and  bladder,  and  eventually  rupture  of 
these  vessels  and  mixture  of  chyle  with  the  urine.  The  urine  is 
clear  in  the  morning  after  fasting. 


66  THE   KIDNEY  [chap,  iv 

PNEUMATURIA 

Gas  is  discharged  with  the  urine  and  appears  usually  at  the 
end  of  micturition,  producing  a  gurgling,  bubbling,  or  whistling 
noise  and  a  peculiar  sensation. 

Pneumaturia  may  result  from  the  introduction  of  air  into  the 
bladder  by  means  of  a  catheter  or  during  evacuation  after  lithotrity. 
The  gas  may  come  from  the  intestine,  escaping  into  the  bladder 
by  a  vesico-intestinal  fistula.  There  may  rarely  be  spontaneous 
development  of  gas  in  the  urinary  tract.  In  some  of  these  cases 
sugar  is  present  in  the  urine,  and  the  pneumaturia  results  from 
fermentation  of  the  sugar  and  the  formation  of  alcohol,  setting  free 
carbonic  acid  gas.  This  results  from  the  action  of  organisms^ 
usually  the  Bacillus  coli  communis,  but  occasionally  the  Proteus 
vulgaris.  Where  sugar  is  not  present  in  the  urine  the  spontaneous 
formation  of  gas  has  been  said  to  be  derived  from  the  blood  or  to 
be  due  to  the  action  on  the  urine  of  gas-producing  bacteria,  such  as 
the  B.  coli  and  the  B.  lactis  aerogenes. 

Treatment. — When  no  fistula  exists,  treatment  consists  in 
removing  the  cause  of  the  fermentation  by  washing  the  bladder 
and  administering  urinary  antiseptics.  Glycosuria  should  be 
treated. 

The  treatment  of  fistula  of  the  bladder  will  be  discussed  later 
(Chap,  xxxix). 

LITERATURE 

Luetscher,  Johns  Hopkins  Hosp.  Bull.,  Oct.,  1911,  p.  261. 
Schnitzler,   Internat.  klin.  Rundschau,  1894,  pp.  265,  306. 
Wildbolz,  Correspond.  Bl.  f.  Schweiz.  Aerzte,  1901   p.  683. 


CHAPTER  V 

CONGENITAL   ABNORMALITIES   OF  THE   KIDNEY 
AND  URETER 

FcETAL  lobulation  of  the  kidneys  occasionally  persists  throughout 
life.  The  only  clinical  importance  of  this  foetal  form  is  that  these 
kidneys,  according  to  the  view  of  some  authorities,  are  specially 
vulnerable  to  disease.  Kiister  and  Wagner  state  that  they  fre- 
quently become  tuberculous. 

Complete  absence  of  both  kidneys  is  most  frequently  found 
in  acephalic  foetuses  and  other  monsters.  The  condition  has  no 
clinical  importance. 

Supernumerary  kidneys  are  rare.  A  third  kidney  has  occasion- 
ally been  found  post  mortem,  and  very  rarely  on  operation. 

CONGENITAL  ABSENCE  OR  ATROPHY  OF  ONE  KIDNEY 
—FUSED  KIDNEYS 

These  conditions  are  of  extreme  practical  importance.  I  col- 
lected 93  cases  of  death  from  uraemia  or  anuria  commencing  within 
the  first  few  days  after  an  operation  on  one  kidney,  and  found 
that  there  was  no  second  kidney  in  10  of  the  cases,  and  that  the 
second  kidney  was  "  completely  atrophied "  in  8.  In  over  19 
per  cent,  of  these  cases,  therefore,  the  fatal  result  was  due  to  the 
absence  or  atrophy  of  one  kidney. 

Congenital  Absence  of  One  Kidney — Unsymmetrical  Kidney 

The  frequency  with  which  unsymmetrical  kidney  or  extreme 
congenital  atrophy  of  the  kidney  occurs  is  about  1  in  2,400  bodies 
(Morris).  The  left  kidney  is  more  frequently  absent  than  the 
right,  and  male  subjects  are  more  frequently  affected  in  the  pro- 
portion of  two  to  one  (left  127,  right  97 — Mankiewicz). 

The  renal  vessels  of  the  side  on  which  the  kidney  is  wanting 
are  usually  absent,  or  are  quite  rudimentary,  being  represented 
by  a  few  small  twigs  which  ramify  in  the  retroperitoneal  fat.  The 
ureter  is  usually  absent  (93  per  cent.).  When  present,  it  is  repre- 
sented  by   a  solid   fibrous   cord   of  varying    length  which   finds 

67 


68  THE   KIDNEY  [chap. 

attachment  to  the  bladder  at  its  lower  end  and  disappears  in  the 
retroperitoneal  fat  at  its  upper  end.  There  may  be  no  trace  of  the 
ureteric  opening,  and  this  half  of  the  trigone  of  the  bladder  may 
be  atrophied.  A  small  dimple  may  sometimes  mark  the  situation 
which  the  ureteric  orifice  would  occupy,  and  sometimes  an  orifice 
is  actually  present  opening  into  a  lumen  which  extends  for  1  to 
2  cm.  along  the  fibrous  cord.  The  suprarenal  gland  is  absent  on 
the  same  side  in  27-7  per  cent,  of  cases. 

Associated  with  congenital  absence  of  one  kidney  there  is  some 
congenital  malformation  in  the  genital  system  in  70-8  per  cent,  of 
cases,  almost  without  exception  found  on  the  same  side  as  the 
renal  defect.  Thus,  in  the  female  subject  there  has  been  uterus 
bicornis  with  imperfect  development  of  the  horn  of  the  uterus 
on  the  side  of  the  absent  kidney,  absence  of  the  uterus,  ovary,  and 
Fallopian  tube,  formation  of  a  septum  in  the  vagina,  and  absence 
of  the  vagina  ;  in  the  male,  absence  or  atrophy  of  the  testis,  vas 
deferens,  and  seminal  vesicle  have  been  observed. 

Other  congenital  malformations  have  also  been  noted,  such  as 
hare-lip  and  cleft  palate,  accessory  auricles,  double  thumbs,  web 
fingers  and  toes. 

The  single  kidney  is  usually  larger  than  the  natural  size,  but 
there  are  cases  in  which  it  is  not  increased  in  size.  Sometimes  the 
organ  may  be  as  much  as  twice  the  size  of  a  normal  kidney,  or 
even  larger.  Such  excessive  growth  cannot  be  regarded  as  due  to 
compensatory  hypertrophy.  It  may  occupy  the  natural  position 
in  the  loin,  or  it  may  sometimes  be  misplaced  and  lie  in  the  iliac 
fossa  or  over  the  lumbar  vertebrae  or  the  sacrum.  The  kidney  is 
sometimes  lobulated,  and  may  have  lost  its  reniform  outline  and 
become  rounded  or  globular  or  even  irregular,  but  more  frequently 
it  retains  its  natural  shape.  The  ureter  is  single  and  enters  the 
bladder  in  the  usual  position.  Occasionally  the  ureteric  orifice  in 
the  bladder  may  be  misplaced  towards  the  middle  line,  or  it  may 
open  in  some  abnormal  position  such  as  the  urethra  or  vas  deferens. 

Congenital  Atrophy  op  One  Kidney 

Congenital  atrophy  to  the  extent  that  the  affected  kidney  is 
almost  obliterated  is  very  rare.  Morris  found  only  3  such  cases  in 
15,904  post-mortem  examinations.  Less  complete  atrophy  of  the 
kidney  is  more  frequently  observed.  The  atrophy  may  be  due  to 
chronic  Bright's  disease,  to  blocking  of  the  ureter,  or  to  embolism. 

The  chief  difference  between  cases  of  extreme  congenital  atrophy 
and  congenital  absence  is  that  in  the  former  some  rudiment  of  the 
kidney  is  always  found  and  the  ureter  is  present,  though  some- 
times merely  in  the  form  of  a  fibrous  cord. 


V]  UNSYMMETRICAL  KIDNEY  69 

The  rudinicntaiy  kidney  may  be  a  fibro-fatty  nodule,  or  it  may 
be  a  fibrous  nodule  with  cysts  and  traces  of  renal  tissue.  The 
shape  and  appearance  may  be  that  of  a  foetal  kidney  with  the  well- 
marked  lobulation. 

Clinical  facts  relating  to  congenital  absence  or  atrophy 
of  one  kidney. — To  the  surgeon,  complete  atrophy  and  total 
absence  are  synonymous  terms. 

A  single  kidney  is  prone  to  be  attacked  by  disease.  Calculus 
is  especially  frequent  in  these  kidneys.  Newman  collected  8  cases 
of  single  kidney  affected  with  calculus ;  Mosler  found  that  9  out 
of  12  cases  of  single  kidney  had  calculi.  Malignant  growths  have 
also  been  observed,  while  cases  of  tuberculous  disease,  hydro-  and 
pyonephrosis,  and  chronic  nephritis  are  recorded. 

Such  diseases  are  rendered  more  serious  by  the  fact  that  they 
develop  in' a  single  kidney.  Apart  from  this,  however,  the  absence 
of  one  kidney  does  not  of  itself  shorten  life.  This  condition  is 
found  in  bodies  from  infancy  to  old  age.  Newman  collected 
17  cases  aged  over  60  years. 

In  the  great  majority  of  cases  of  single  kidney  the  condition 
has  been  found  accidentally  post  mortem.  A  few  cases  of  nephrec- 
tomy of  a  single  kidney  are  recorded.  I  have  collected  18  such 
cases.  It  is  imperative,  therefore,  that  proof  of  the  presence  of 
a  second  kidney  should  be  obtained  whenever  nephrectomy  is 
proposed. 

The  presence  of  some  congenital  abnormality  of  the  genital 
organs,  or  even  some  congenital  malformation  elsewhere,  should 
put  the  surgeon  on  his  guard  when  dealing  with  a  case  of  kidney 
disease.  In  103  cases  of  congenital  absence  of  the  kidneys  col- 
lected by  Ballowitz,  where  the  state  of  the  genital  organs  w^as 
mentioned,  there  were  73  (70-8  per  cent.)  in  which  some  mal- 
formation was  present,  and  the  majority  of  these  were  females 
(28  male  and  41  female). 

The  following  means  may  be  used  to  obtain  proof  of  the 
presence  of  a  second  kidney,  viz.  (1)  cystoscopy,  (2)  catheteriza- 
tion of  the  ureters,  (3)  lumbar  exploration. 

1.  Cystoscopy. — In  those  cases  where  a  kidney  is  congenitally 
absent  the  ureter  is  also  absent,  and  there  is,  in  many  cases,  no 
ureteric  opening  in  the  bladder. 

The  ureteric  orifice  is  absent  in  33-3  per  cent,  of  such  cases 
(73  in  234  cases — Mankiewicz).  It  will  therefore  be  possible, to 
make  a  diagnosis  of  congenital  absence  of  a  kidney  by  cystoscopy 
in  one-third  of  the  cases.  Rarely  the  half  of  the  trigone  is  absent 
or  rudimentary  on  the  side  of  the  absent  kidney  (Fig.  18).  This  has 
been  observed  on  the  left  side  (4  cases)  but  not  on  the  right.     In  some 


70  THE  KIDNEY  [chap. 

cases  a  dimple  may  be  seen  in  the  position  of  the  ureteric  orifice. 
In  a  small  number  of  cases  there  is  a  normal  ureteric  orifice  which 
leads  into  a  short  tunnel  in  a  rudimentary  ureter  extending  upwards 
for  a  few  centimetres.  In  such  a  ureter  the  normal  rhythmic  con- 
tractions of  the  functioning  ureter  are  absent,  and  there  is  no 
efflux.  It  does  not  follow,  however,  that  every  ureter  that  is 
motionless  under  observation  lacks  a  functional  kidney.  It  fre- 
quently happens  that  while  the  surgeon  is  examining  the  ureteric 
orifice  the  ureter  ceases  to  contract,  and  there  may  be  a  pause  of 
several  minutes'  duration. 

2.  Catheterization  of  the  ureters. — By  this  method  there  is  pro- 
vided a  means  of  proving  that  a  patent  ureter  exists,  and  that  a 


Fig.  18. — Bladder  and  prostatic  urethra  in  a  case  of  solitary 
kidney,  showing  absence  of  left  half  of  trigone  and  of  left 
ureteric  orifice. 

functionally  active  kidney  is  present,  and  the  functional  value 
of  the  kidney  may  be  tested  by  the  various  methods  which  have 
already  been  described  (p.  20). 

If  the  catheter  passes  12  or  13  in.  along  the  ureter  without 
hindrance,  the  patency  of  the  duct  is  demonstrated ;  but  if  the 
catheter  is  arrested  at  some  point  near  the  bladder  orifice,  it  does 
not  follow  that  the  lumen  ends  here.  The  point  of  the  catheter 
may  be  arrested  by  catching  in  a  fold  of  mucous  membrane,  especially 
where  there  is  over-  or  under-distension  of  the  bladder,  or  a  loaded 
rectum.  A  catheter  with  a  smooth,  rounded  end  is  the  best  for 
use  where  such  a  fold  is  encountered,  and  various  degrees  of  dis- 
tension of  the  bladder  and  elevation  of  the  pelvis  should  be  tried, 
and,  if  necessary,  the  rectum  should  be  unloaded  with  an  enema. 
A  general  anaesthetic  may  give  assistance. 


V]  SOLITARY   KIDNEY  71 

There  are  also  pathological  causes  for  the  catheter  being  arrested 
at  some  point  in  the  ureter,  but  these  need  not  be  discussed  here, 
for  their  presence  will  already  have  led  to  the  conclusion  that  a 
kidney  exists  on  this  side.  The  withdrawal  of  urine  from  a  catheter 
lodged  in  a  ureter  is  an  almost  certain  proof  that  a  kidney  exists 
on  this  side.  There  are,  however,  rare  cases  in  which  two  ureters 
arise  from  one  kidney,  and  open  into  the  bladder  in  the  normal 
position  {see  p.  75).  Pyelography  (p.  42)  will  give  valuable  in- 
formation in  such  cases. 

3.  Lumbar  exploration  of  the  kidney. — A  preliminary  operation 
may  be  performed  to  demonstrate  the  presence  of  the  second 
kidney.  The  organ  is  exposed  by  a  lumbar  incision,  and,  if  a  kidney 
be  found,  the  size,  appearance,  consistence,  and  the  microscopical 
character  of  a  sUp  cut  from  its  substance  are  examined. 

Unless  there  is  some  suspicion  as  to  the  absence  or  atrophy  or 
disease  of  a  second  kidney,  this  method  is  not  likely  to  be  used, 
but  should  the  other  methods  already  described  fail,  and  a  sus- 
picion of  such  a  condition  be  raised,  the  use  of  lumbar  exploration 
is  fully  justified. 

Operative  interference  in  a  single  kidney  has  been  frequently 
undertaken,  in  most  cases  without  previous  knowledge  that  the 
kidney  attacked  was  a  single  organ.  Winter  records  4  cases  of 
nephrolithotomy  for  calculous  anuria  in  a  single  kidney  where  the 
patients  recovered.  In  18  cases  of  death  from  anuria  after  opera- 
tion upon  a  kidney,  where  the  other  kidney  was  completely  atrophied 
or  absent,  I  found  that  nephrotomy  had  been  performed  for  tuber- 
culosis once  and  for  stone  once.  In  the  remaining  16  cases  nephrec- 
tomy of  the  single  kidney  was  performed  for  the  following  condi- 
tions :  Tuberculosis  3,  calculus  3,  hydronephrosis  4,  displaced  and 
floating  kidney  3,  cystic  and  hydatid  cyst  2,  carcinoma  1. 

Solitary  or  Fused  Kidney 

Fusion  of  the  kidneys  into  one  mass  gives  rise  to  an  organ  pre- 
senting great  variety  in  shape  and  size.  The  lowest  degree  of  fusion 
is  found  where  two  kidneys  are  united  by  a  fibrous  band,  and  the 
highest  where  the  two  kidneys  are  indistinguishably  fused  in  a 
single  mass.  Different  names  have  been  conferred  upon  some 
of  the  varieties.  There  are  the  horseshoe  kidney,  the  S-shaped 
kidney,  the  long  kidney,  the  shield-like  kidney,  etc.  Some  of  these 
merit  further  notice. 

The  horseshoe  kidney. — This  represents  the  most  common 
and  the  smallest  degree  of  fusion.  Morris  found  the  frequency  of 
horseshoe  kidney  to  be  1  in  1,000. 

The  horseshoe  is  formed  bv  a  union  of  the  lower  ends  of  the 


72 


THE   KIDNEY 


[chap. 


kidneys  by  means  of  a  band  passing  across  the  aorta  and  vena 
cava.  More  rarely  the  upper  ends  of  the  kidneys  are  united  so  that 
the  concavity  is  downwards.  The  fused  kidneys  He  nearer  the 
middle  line  than  normal,  and  they  are  usually  misplaced  downwards. 
The  misplacement  is  never  so  great  as  in  the  more  complete  forms  of 
fusion,  but  the  uniting  band  frequently  lies  as  low  as  the  bifurcation 
of  the  aorta.  The  bond  of  union  may  be  merely  a  fiat  band  of 
fibrous  tissue,  or  it  may  be  composed  of  renal  tissue,  which  is  spread 
out  into  a  thin  layer,  or  forms  a  bulky  mass  uniting  the  lateral 
organs.  The  traces  of  a  median  division  have  sometimes  been 
observed  on  the  anterior  surface  of  the  isthmus.     The  uniting  mass 


Fig.   19. — Horseshoe  kidney  and  abnormal  renal  vessels, 
ureters  pass  in  front  of  the  uniting  band. 


The 


has  taken  the  form  of  a  third  kidney,  to  each  pole  of  which  the 
lower  pole  of  an  abnormally  placed  kidney  was  welded  (E,ayer) ; 
or  the  kidneys  may  be  united  by  a  large  quadrilateral  mass.  One 
kidney  may  be  much  smaller  than  the  other. 

The  blood-vessels  of  each  kidney  may  be  normal  in  number, 
but  abnormalities  of  character  and  distribution  have  frequently 
been  recorded  (Fig.  19),  and  are  found  in  the  more  complete  degrees 
of  fusion  rather  than  in  the  more  perfectly  formed  kidneys.  They 
may  be  asymmetrical.  An  increase  in  the  number  of  arteries  is 
frequent,  and  the  isthmus  may  receive  a  special  artery.  The  prin- 
cipal artery  of  each  kidney  arises  from  the  aorta  above  the  level  of 
the  renal  pelvis  and  passes  downwards  in  front  of  the  pelvis.     A 


V]  HORSESHOE   KIDNEY  73 

smaller  artery  arises  at  each  side  from  the  aorta  or  iliac  artery 
below  the  kidney  and  ascends  to  the  lower  pole  of  each  kidney. 
Considerable  variation  is  observed  in  the  renal  pelvis  and  ureter. 
Each  kidney  has  usually  a  single  pelvis  and  ureter,  the  ureter  passing 
over  the  front  of,  very  rarely  behind,  the  uniting  band  (Fig.  19). 
The  pelves  may  be  increased  in  number  and  irregular  in  form,  and 
are  turned  more  to  the  front  than  normal.  Very  rarely  the  isthmus 
possesses  a  special  ureter,  which  opens  into  the  bladder  in  the 
position  normally  occupied  by  one  ureter,  while  the  ureter  belong- 
ing to  one  of  the  kidneys  is  misplaced  and  opens  into  the  bladder 
in  some  unusual  position. 

Diagnosis. — The  clinical  diagnosis  before  operation  of  a  diseased 
horseshoe  kidney  has  only  once  been  made,  and  that  by  Israel, 
in  a  student  of  medicine  aged  23  years.  The  patient  had  suffered 
for  four  years  from  attacks  of  pain  in  the  back  and  right  side, 
recurring  every  fourteen  days  and  accompanied  by  diminution  of 
the  urine.  During  an  attack  there  was  an  ill-defined  swelUng  in 
the  gall-bladder  region,  which  reached  as  low  down  as  the  umbihcus. 
It  was  tender,  and  did  not  move  with  respiration  or  in  varying 
positions  of  the  body.  The  kidneys  could  not  be  felt  in  the  normal 
position.  The  diagnosis  of  a  horseshoe  kidney  depended  upon  the 
median  position  of  the  swelhng  and  the  impossibility  of  feeling 
the  kidneys  in  the  normal  position,  and  this  was  confirmed  by 
operation. 

Suggestions  have  been  made  by  different  authors  for  the 
diagnosis  of  disease  in  horseshoe  kidneys.  According  to  Konig,  one 
may  suspect  a  horseshoe  kidney  if  one  feels  a  horseshoe-like  swelling 
in  front  of  the  lumbar  vertebras.  In  a  case  in  which  Kiimmel 
operated  for  stone  and  hydronephrosis  in  one  half  of  a  horseshoe 
kidney,  the  shadows  in  the  radiograph  were  situated  immediately 
adjacent  to  the  bones  of  the  2nd  and  3rd  lumbar  vertebrse,  obscur- 
ing the  transverse  processes  ;  and  he  suggests  that  the  median 
position  of  the  shadows  should  raise  the  suspicion  of  a  horseshoe 
kidney.  Burghart  regards  as  supremely  important  the  detection 
of  a  large,  pulsating,  somewhat  elastic  tumour  with  irregular  con- 
tour in  front  of  and  below  the  abdominal  aorta,  and  over  which  a 
systolic  bruit  is  audible,  while  there  is  no  delay  in  the  pulse  in  the 
peripheral  arteries.  Davidsohn  found  hypertrophy  of  the  heart 
from  compression  of  the  aorta  by  the  transverse  band. 

This  malformation  of  the  kidney  and  also  the  fixed  misplaced 
kidney  have  been  mistaken  for  a  mahgnant  gro^Ai:h.  Oliver  relates 
such  a  case. 

Pyelography  with  an  opaque  catheter  in  the  ureter  should  enable 
a  diagnosis  to.  be  made  in  such  cases  (p.  42). 


74 


THE   KIDNEY 


[chap. 


The  long  simple  kidney  and  the  S-shaped  kidney. — In  both 
these  varieties  there  is  an  end-to-end.  fusion  of  the  kidneys,  and 
the  combined  organ  is  situated  on  one  side  of  the  vertebral  column. 
In  the  simple  long  kidney  the  hilus  of  both  the  component  kidneys 
is  turned  in  the  same  direction.  The  ureter  of  the  upper  kidney 
passes  to  the  opposite  side  of  the  bladder  and  opens  in  the  normal 
position,  and  there  is  thus  no  crossing  of  the  ureters.  Both 
ureters  have  been  known  to  open  on  the  same  side  of  the  bladder. 
In  the  S-shaped  kidney,  or  sigmoid  kidney,  the  pelves  of  the 
component  kidneys   face   in    opposite  directions    (Fig.  20).     The 

ureters  may  run  parallel,  or  they  may 
cross  and  open  into  opposite  sides  of 
the  bladder. 

The  shield-like  or  discoid  kidney. 
— The  kidneys  are  completely  fused,  and 
form  a  large,  flat,  lobulated  mass,  which 
usually  lies  in  the  middle  line  of  the 
body,  low  down  about  the  bifurcation  of 
the  aorta.  There  are  usually  two  ureters, 
very  rarely  one.  Another  form  of  fused 
kidney  is  quite  irregular  in  shape  and 
in  the  number  and  distribution  of  the 
vessels.  I  have  recorded  an  example  of 
this  form  of  kidney,  for  which  I  am 
indebted  to  Prof.  Johnston  Symington 
of  Belfast.  (Fig.  21.)  This  occurred  in 
a  female  subject  aged  19.  There  was  no 
kidney  on  the  left  side.  On  the  right  side 
a  kidney  was  situated  in  the  right  iliac 
fossa,  and  extended  upwards  to  the  level 
of  the  intervertebral  disc  between  the  3rd 
and  4th  lumbar  vertebrae.  The  lower  por- 
tion was  bent  nearly  to  a  right  angle  with  the  upper  part,  and  dipped 
into  the  pelvis,  extending  as  low  as  the  3rd  sacral  vertebra.  The 
kidney  mass  was  supplied  by  three  renal  arteries,  one  from  the 
right  side  of  the  aorta,  one  from  the  right  common  iliac,  and  a  third 
from  the  bifurcation  of  the  aorta.  There  were  two  ureters,  which 
passed  down  and  opened  into  the  bladder  in  the  usual  situations. 

MISPLACED   KIDNEYS 

Fixed  misplacements  are  almost  invariably  congenital,  movable 
displacements  are  usually  acquired.  Fixed  misplacements  only 
will  be  discussed  in  this  place.  The  movable  displaced  kidney  will 
be  considered  later. 


Fig.  20.— Sigmoid  kid- 
ney.    {After  Br  OS  ike.) 


V] 


MISPLACED   KIDNEY 


75 


III  the  inalformation  of  the  kidney  described  above  it  was  noted 
that  in  the  slighter  degrees  of  fusion  of  the  organs  the  kidneys  were 
either  normally  placed  or  were  misplaced  downwards  to  a  slight 
degree,  whereas  in  the  more  severe  degrees  of  malformation  the 
misplacement  was  considerable.     It  follows,  therefore,  that  when 


Fig.  21. — Solitary  misplaced  kidney  with  two  ureters,  each  of 
which  opened  in  the  natural  position  in  the  bladder. 

we  consider  fixed  misplacements  of  the  organs,  many  of  the  kidneys 
are  malformed.  A  few  fixed  misplaced  kidneys  are  normal  in  size 
and  contour,  but  there  is  considerable  malformation  of  the  misplaced 
organ  in  the  great  majority  of  cases.  The  remaining  kidney,  if 
not  fused,  may  be  normal  in  structure  and  position  ;  but  occasionally 


76  THE   KIDNEY  [chap. 

there  is  no  second  kidney,  or  it  is  atrophied.  The  position  of  the 
misplaced  kidney  is  at  the  bifurcation  of  the  aorta,  on  the  pro- 
montory of  the  sacrum,  over  the  sacro-iliac  synchondrosis,  in  the 
ihac  fossa,  or  in  the  hollow  of  the  sacrum.  The  suprarenal  capsule 
is  misplaced  with  the  kidney  in  9  out  of  24  cases  (Newman).  Both 
kidneys  may  be  misplaced.  If  only  one  kidney  is  misplaced,  it 
is  more  frequently  the  left.  The  frequency  with  which  fixed  mis- 
placements of  the  kidney  occur  is  about  1  in  1,000  bodies  (Morris 
found  13  in  12,768). 

Where  the  left  kidney  is  misplaced  the  descending  colon  crosses 
the  middle  line,  and  the  first  part  of  the  rectum  is  on  the  right 
side  of  the  sacrum.  The  vessels  are  usually  abnormal  in  origin, 
number,  and  distribution.  The  renal  artery  may  spring  from  the 
bifurcation  of  the  aorta  or  from  the  iliac  artery.  Genital  malforma- 
tions are  as  frequently  found  with  malplaced  as  with  malformed 
kidneys. 

Symptoms. — The  pelvic  kidney  (Beckenniere)  is  more  frequent 
in  men  than  in  women,  but  it  is  more  likely  to  cause  trouble  in 
women.  It  gives  rise  to  disturbances  of  menstruation,  of  preg- 
nancy, and  of  parturition.  Apart  from  disease,  to  which  these 
kidneys  are  unduly  liable,  most  cases  of  renal  misplacement  cause 
no  clinical  symptoms. 

As  Israel  points  out,  disease  of  a  misplaced  kidney  frequently 
gives  rise  to  pain  in  the  corresponding  lumbar  region,  and  is  apt  to 
distract  attention  from  the  real  cause  of  the  symptom.  Persistent 
interference  with  defsecation  has  been  noted  as  a  symptom. 

Wehmer  considers  the  following  points  important  in  the  diagnosis 
of  a  misplaced  kidney  : — ■ 

1.  The  discovery  of  a  tumour  lying  upon  the  promontory  or 
sacrum. 

2.  The  absence  of  the  kidney  from  the  same  side. 

3.  Together  with  these,  the  presence  of  pyuria  or  hsematuria, 
and  of  spasm  of  the  bladder,  especially  connected  with  menstruation 
in  women. 

4.  The  demonstration  of  an  abnormal  course  of  the  rectum  by 
means  of  air  inflation. 

5.  Exclusion  of  origin  of  the  tumour  from  the  pelvic  organs. 
Ovarian  cysts  and  hydatid  cysts  are  most  difficult  to  distinguish. 

Hochenegg  felt  the  pulsation  of  several  arteries  on  the  anterior 
surface  of  the  tumour,  which  corresponds  to  the  hilum,  and  found 
a  very  short  ureter  on  catheterization.  Psychic  disturbances  are 
noted  by  Hochenegg  and  Israel  as  accompanying  congenital  mis- 
placement of  the  kidney. 

The  only  published  clinical  preoperative  diagnosis  of  a  pelvic 


V]  MISPLACED   KIDNEY  77 

kidney  has  been  made  by  Miillerheim.  Israel  suggested  such  a 
condition  as  extremely  probable  in  a  patient  sent  to  him  as  a  case 
of  malignant  growth  of  the  rectum,  and  his  suggestion  proved 
correct.  When  a  doubtful  tumour  is  found  in  this  situation,  an 
exploratory  laparotomy  has  been  necessary  to  make  a  diagnosis. 
Catheterization  of  the  ureter  with  an  opaque  bougie  and  pyelo- 
graphy would  make  the  renal  nature  of  such  a  tumour  clear. 

Treatment. — When  the  nature  of  the  tumour  has  been  recog- 
nized it  will  be  necessary  to  have  certain  proof  of  the  presence 
and  activity  of  a  second  organ  before  removing  the  misplaced 
kidney.  When  this  is  obtained,  Wagner  recommends  the  removal 
of  the  misplaced  organ,  even  if  it  is  normal,  where  profound  psvchic 
disturbances  are  present,  or  where  interference  with  the  bowel 
causes  general  symptoms. 

Frank  found  a  peh^c  left  kidney  and  a  malformed  uterus  on 
laparotomy,  and  displaced  the  kidney  upwards  above  the  brim  of 
the  pelvis,  and  fixed  it  there. 

Nephrectomy  has  frequently  been  performed. 

Israel  removed  the  kidney  extraperitoneally  by  a  lateral  incision, 
after  allowing  an  exploratory  laparotomy  wound  to  heal.  Cragin 
removed  a  misplaced  kidney  through  the  vagina,  and  Hochenegg 
another  by  a  sacral  route.  Two  cases  are  on  record  in  which  a 
solitary  misplaced  kidney  was  removed  from  the  pehas  (Buss  and 
Polk).  In  both  cases  there  was  maldevelopment  of  the  genital 
organs.  The  patients  died,  on  the  seventh  and  eleventh  days 
respectively,  of  uraemia. 

LITERATURE 

Ballowitz,  Virchows  Arch.,  1895,  clxi.  309. 

Buss,  Zeits.  f.  Min.  Med.,  xxxviii.  4,  5,  6. 

Heiner,  Folia   Urol.,  Oct.,  1908. 

Israel,  Nierenkrankkeiten,  1901  :    Berl.  klin.  Woch.,  1889,  xsvi.  71.5. 

Kiimmel,  Arch.  /.  klin.  Chir.,  1901,  vol.  Ixiv. 

Manby,  Lancet,  1885,  i.  161. 

Mankiewicz,  Centralhl.  f.  d.  Krankh.  d.   Hum-  u.  Sex.-Org.,  1900,  v.  513. 

Morris,  Surgical  Diseases  of  the  Kidney  and  Ureter,  vol.  i.     1901. 

Miillerheira,  Deuts.  mcd.  Woch.,  1902,  xxviii.  46. 

Newman,  Scot.  Med.  Surg.  Joitrn.,  vol.  i.,  Xo.  1,  p.  53  ;    Movable  Kidney, 

Oliver,  Brit.  Med.  Journ.,  Feb.  26,  1898.  [1907. 

Owen,  Med.  Press  and  Circ,  May  10,  1899. 

Polk,  Xew   York  Med.  Journ.,  Feb.  17,  1883. 

Preindlsberger,  Wien.  klin.  Rundschau,  1901,  p.  197. 

Walker,  Thomson,  Renal  Function  in  Urinary  Surgery,  p.  155.     1908. 

Ward,  Brit.  Med.   Journ.,  1908,  1.  978. 

Winter,  Arch.  /.  klin.  Chir.,  1903,  vol.  Ixix. 


CHAPTER  VI 

MOVABLE  AND  FLOATING  KIDNEY 

The  normal  kidney  descends  with  inspiration  and  ascends  with 
expiration,  the  excursion  varying  from  |-  to  1|  in.  In  many  normal 
individuals  where  the  abdominal  wall  is  not  thick  or  resistant,  the 
lower  pole  of  the  right  and  sometimes  of  the  left  kidney  can  be  felt. 

Where  one-half  or  more  of  the  kidney  can  be  felt  and  grasped 
between  the  fingers  on  inspiration  the  organ  is  unduly  movable. 

Anatomy  of  movable  and  of  floating:  kidney. — A  floating 
kidney  is  entirely  surrounded  by  peritoneum,  which  also  clothes 
its  pedicle  and  forms  a  mesonephros.  A  floating  kidney  is  a  con- 
genital malformation,  and  is  very  rare.  It  cannot  be  diagnosed 
from  a  movable  kidney  without  operation,  and  an  intraperitoneal 
operation  is  required  for  its  relief. 

A  movable  kidney  moves  behind  the  peritoneum  and  remains 
an  extraperitoneal  organ. 

The  movable  kidney  moves  within  the  perirenal  fascia.  The 
perirenal  fascia  is  often  greatly  thickened,  and  the  perirenal  space 
enclosed  within  its  layers  is  elongated.  The  delicate  perirenal  fat 
immediately  surrounding  the  organ  is  usually  diminished  in  amount, 
and  sometimes  is  entirely  absent ;  it  is  occasionally  present  in 
considerable  quantity.  The  fine  fibrous  threads  which  normally 
connect  the  fibrous  capsule  of  the  kidney  with  the  perirenal  fascia 
and  cross  the  fatty  envelope  are  thicker,  tougher,  and  longer  than 
in  the  normal  state.  The  fibrous  capsule  may  present  no  change, 
but  milky  patches  of  thickening  are  frequently  observed  and  often 
the  whole  capsule  is  thicker  and  tougher.  It  strips  easily  from  the 
cortex  of  the  kidney.  The  renal  vessels  are  elongated,  the  artery 
more  so  than  the  vein,  as  a  result  of  the  rigidity  of  the  aorta  com- 
pared with  the  vena  cava.  The  walls  of  the  renal  vessels  are  usually 
thickened.  There  is  no  inflammatory  matting  of  the  vascular 
pedicle.  Except  in  the  rarest  cases,  the  suprarenal  capsule  retains 
its  normal  position. 

The  attachments  of  the  kidney  to  the  duodenum  and  ascending 
colon  on  the  right  side  and  the  pancreas  and  descending  colon  on 

78 


VI]  MOVABLE   KIDNEY  79 

the  left  are  usually  separated.  Thick  bands  of  adhesions  between 
the  kidney  and  the  colon  may,  however,  be  found,  and  adhesions 
may  form  between  the  right  kidney  and  the  duodenum.  The 
kidney  mav  become  adherent  to  the  structures  surrounding  it  in 
an  abnormal  position,  such  as  the  iliac  fossa. 

The  kidney  has  been  found  in  a  congenital  lumbar  hernia  and 
in  a  diaphragmatic  hernia.  I  have  met  with  a  case  in  which  a 
kidney  could  be  completely  projected  by  straining  or  coughing  into 
a  thin-walled  lumbar  hernia  which  had  resulted  from  a  badly 
repaired  lumbar  incision.  The  kidney  could  be  grasped  in  the 
fingers  and  its  outline  and  pedicle  traced. 

Changes  in  the  kidney  substance  may  be  referred  either  to 
interference  with  the  blood  supply  or  to  obstruction  of  the  out- 
flow of  urine,  and  they  may  be  acute  or  chronic. 

Torsion  of  the  pedicle  may  occur  even  when  a  movable  kidney 
has  but  a  moderate  range  of  mobility.  The  renal  vein  obstructed, 
the  organ  becomes  engorged  with  blood.  The  kidney  is  enlarged 
and  dark  purple  in  appearance,  and  the  fibrous  capsule  may  be 
raised  up  by  subcapsular  haemorrhages.  The  urine  is  partly,  and 
may  be  completely,  suppressed.  It  contains  blood  and  blood 
casts.  After  a  time  the  torsion  is  relieved  and  the  kidney  returns 
to  its  normal  condition. 

Kinking  or  twisting  of  the  ureter  may  be  caused  by  rotation  of 
the  kidney  on  its  transverse  axis  and  twisting  of  the  ureter  over 
the  renal  vessels,  or  by  the  kidney  swinging  at  the  end  of  its  vascular 
pedicle  and  causing  the  ureter  to  become  folded  so  that  its  lumen 
is  occluded.  The  normal  ureter  is  extremely  mobile,  and  some 
degree  of  fixation  by  adhesions  is  necessary  before  kinking  or  test- 
ing of  the  tube  can  produce  obstruction.  (Plate  2,  Fig.  3,  facing 
p.  42.)  The  urine  is  pent  up,  and  the  pelvis  distended.  By  pres- 
sure the  pyramids  of  the  kidney  become  flattened  and  the  kidney 
is  hollowed  out,  until  eventually  only  a  thin  layer  of  kidney  sub- 
stance remains.  This  condition  is  brought  about  by  repeated 
attacks  of  obstruction  of  the  ureter,  which  give  rise  to  intermittent 
hydronephrosis.  The  upper  end  of  the  ureter  is  frequently  found 
adherent  for  an  inch  or  more  to  the  surface  of  the  dilated  pehds. 

Chronic  interstitial  nephritis  may  be  present  in  a  movable 
kidney,  and  is  due  either  to  interference  with  the  circulation  or  to 
pressure  from  obstruction  of  the  ureter. 

Occasionally  the  undue  mobility  of  the  kidney  is  accompanied 
by  enteroptosis.     The  stomach  is  frequently  dilated. 

The  movable  kidney  may  be  the  seat  of  stone,  tuberculosis,  or 
new  growth,  or  there  may  be  hydronephrosis,  caused  by  folding  of 
the  ureter  oyer  an  abnormal  blood-vessel. 


80  THE   KIDNEY  [chap. 

Statistics   of   frequency,  sex,  age,  and   side   affected. — 

The  frequency  of  movable  kidney  is  variously  stated  as  from 
44  per  cent,  to  56  per  cent,  in  women,  and  0-48  per  cent,  to  6  per 
cent,  in  men.  At  most,  from  5  to  10  per  cent,  of  women  and  from 
J  to  1  per  cent,  of  men  have  an  abnormally  movable  kidney.  A 
smaller  number  suffer  from  symptoms  caused  by  the  undue  mobility. 
The  average  age  is  33 1  years  (Mc Williams).  The  right  kidney  is 
affected  in  8  of  every  10  cases,  and  both  kidneys  in  5  per  cent,  of 
cases. 

Etiology. — ^No  one  cause  will  satisfactorily  explain  the  occur- 
rence of  abnormal  mobility  of  the  kidneys  in  all  cases. 

Three  facts  must  be  explained  by  any  fundamental  cause  of 
movable  kidney :  (1)  the  preponderance  of  the  condition  in  women 
(8  in  9  cases) ;  (2)  the  frequency  with  which  the  right  side  is  affected 
(8  in  10  cases)  ;  (3)  the  prevalence  of  the  condition  between  the 
ages  of  20  and  50. 

The  following  factors  are  of  importance : — 

1.  Congenital  mobility. — Congenital  nephroptosis  has  been 
observed  by  Dr.  W.  R.  Stewart  and  others,  but  the  cases  were 
examples  of  floating  kidney.  It  is  exceptional  to  meet  with  movable 
kidneys  in  children,  and  the  condition  develops  at  some  period 
after  puberty. 

2.  Anatomical  factors. — The  kidneys  lie  in  a  shallow  recess 
on  each  side  of  the  vertebral  bodies,  the  paravertebral  fossa. 
Wolkow  and  Delitzen  state  that  in  those  persons  with  abnormally 
movable  kidneys  the  paravertebral  fossae  are  shallow  and  more 
.widely  open  at  their  lower  ends  than  in  normal  individuals.  In 
women  they  are  shallower  and  more  open  than  in  men,  and  on 
the  right  side  more  than  on  the  left. 

According  to  Mansell  Moullin  there  is  a  slight  rotation  of  the 
vertebrae  to  the  right  in  a  large  number  of  right-sided  people,  and 
this  makes  the  right  lumbar  recess  shallower. 

The  liver  does  not  cause  downward  displacement  of  the  right 
kidney. 

Becker  and  Lennhof  look  upon  the  build  of  the  trunk  as  an 
important  predisposing  factor.  Women  with  a  long  trunk  and 
narrow  waist  more  frequently  have  movable  kidney  than  those 
with  a  short  trunk  and  broad  waist.  These  authors  constructed  a 
body  index  as  follows  :  The  distance  in  centimetres  from  the  supra- 
sternal notch  to  the  upper  margin  of  the  symphysis  pubis  is  divided 
by  the  narrowest  circumference  of  the  abdomen  and  multiplied 
by  100.  The  normal  quotient  is  75.  Where  the  quotient  is  above 
75  one  kidney  will  be  movable ;  where  it  is  below  this  figure  there 
is  no  movable  kidney.     This  method  has  been  elaborated  by  Harris, 


VI]  MOVABLE   KIDNEY:   ETIOLOGY  81 

who  used  the  level  of  the  tip  of  the  10th  costal  cartilage  as  a  more 
exact  transverse  measurement.  He  also  used  a  series  of  lateral 
and  antero-posterior  measurements  made  with  calUpers  to  show 
that  there  was  a  diminution  in  the  size  of  the  zone  at  the  level  of 
the  10th  rib  in  cases  of  movable  kidney. 

3.  Atrophy  of  the  perirenal  adipose  capsule. — In  rapid 
emaciation  the  perirenal  fat  frequently  disappears,  and  the  kidney 
becomes  unduly  movable.  This  can  only  be  a  factor  in  the  causa- 
tion of  a  few  cases  of  movable  kidney. 

4.  Weakness  of  the  abdominal  walls. — Glenard  states  that 
general  enteroptosis  always  accompanies  movable  kidney,  and 
results  from  weakness  of  the  abdominal  walls.  This  has  been  dis- 
proved by  several  observers.  Grodard-Danhieux  examined  131 
cases  of  movable  kidney  without  finding  enteroptosis.  Einhorn 
observed  27  cases  of  enteroptosis  in  which  the  kidneys  were  not 
movable.  Where  enteroptosis  and  nephroptosis  coexist,  they  do 
not  bear  the  relation  of  cause  and  effect. 

The  relaxation  of  the  abdominal  wall  after  repeated  pregnancies 
probably  explains  some  cases,  but  movable  kidney  is  frequently 
found  in  young  nulliparae  with  strong  abdominal  muscles. 

In  61  cases  of  movable  kidney,  38  of  the  patients  were  married, 
and  of  these  only  22  had  borne  children  (Mc Williams). 

5.  Injury  and  pressure. — In  11-4  per  cent,  of  cases  there  is 
a  distinct  history  of  a  blow,  severe  muscular  strain,  or  other  injury 
in  the  region  of  the  kidney,  which  preceded  the  discovery  of  the 
movable  kidney. 

The  wearing  of  corsets  has  been  stated  to  cause  movable  kidney. 
The  waist  line  is,  however,  below  the  lower  pole  of  the  kidney, 
and,  unless  undue  pressure  is  exerted  at  the  upper  part  of  the 
abdomen,  the  corset  gives  support  to  the  kidney  rather  than 
causes  its  displacement.  In  races  in  which  the  corset  is  not  worn 
movable  kidney  is  observed. 

6.  Drag  of  adhesions  between  the  kidney  and  bowel. — 
Bands  of  adhesions,  probably  secondary  to  chronic  constipation, 
pass  between  the  caecum  and  ascending  colon  and  the  right  kidney, 
and  the  drag  of  these  is  a  cause  of  movable  kidney  (Arbuthnot 
Lane).  Adhesions  may  also  be  observed  between  the  descending 
colon  and  the  left  kidney. 

7.  Pathological  conditions  of  the  kidney. — Tumours  of 
the  kidney,  hydronephrosis,  renal  calculus,  or  other  disease  may 
coexist  with  movable  kidney,  and  in  some  cases  may  appear  to 
be  a  contributory  factor  in  the  causation  of  the  mobility. 

Symptoms. — A  movable  kidney  may  have  a  wide  range  of 
movement  and  be  unaccompanied  by  symptoms.     When  a  patient 


82 


THE  KIDNEY 


[chap. 


with  a  movable  kidney  discovers  the  abnormahty  subjective  symp- 
toms frequently  develop,  and  it  is  generally  accepted  as  unwise 
to  inform  a  patient  of  the  presence  of  undue  mobility  of  the 
kidney  if  no  symptoms  exist.  The  symptoms  which  accompany 
movable  kidney  may  be  directly  connected  with  the  kidney,  or 
they  may  be  referred  to  other  organs. 

1.  Symptoms  referred  to  the  kidney. — These  are  (a)  pain 
and  discomfort,  (b)  undue  mobility,  (c)  enlargement  of  the  kidney, 
and  (d)  changes  in  the  urine. 

(a)  Pain  and  discomfort. — The  patient  is  often  conscious  of  the 
movement  of  the  kidney  within  the  abdomen.  Renal  pain  is  felt 
in  two  positions — posteriorly,  at  the  angle  formed  by  the  last  rib 

with  the  erector  spinse  mass 
of  muscle ;  and  anteriorly,  at 
a  point  about  2  in.  below  and 
internal  to  the  tip  of  the  9th 
costal  cartilage.  This  corre- 
sponds to  the  position  of  the 
pelvis  and  vascular  pedicle. 
The  anterior  area  is  that 
most  frequently  affected,  and 
the  pain  is  usually  of  a  heavy 
aching  character.  There  may 
also  be  attacks  of  severe  pain 
on  the  side  of  the  abdomen 
on  which  the  kidney  is  mov- 
able, and  this  pain  is  most 
severe  at  the  point  indicated 
above.  These  attacks  are 
followed  by  tenderness  and 
sometimes  by  enlargement  of 
the  kidney. 

The  pain  of  movable  kidney  is  initiated  or  aggravated  by  move- 
ment and  relieved  by  rest.  It  is  sometimes  first  experienced  on 
turning  in  bed,  and  may  be  felt  on  lying  in  certain  positions.  The 
aching  is  increased  during  the  menstrual  period. 

(b)  Undue  mobility  of  the  kidney. — In  examining  the  kidney  the 
patient  should  be  placed  in  the  recumbent  position  described  on 
p.  32.  The  examination  should  be  made  with  gentle,  firm  pres- 
sure, the  fingers  of  the  examining  hand  sinking  into  the  abdomen 
at  each  expiration  and  holding  their  position  at  inspiration.  She 
should  also  be  examined  standing  up  facing  the  surgeon.  If  the 
loin  can  be  grasped  with  the  hand,  the  thumb  should  be  placed  in 
front  above  the  upper  pole  of  the  displaced  kidney  with  the  fingers 


Fig.  22. — Chart  of  areas  of  mo- 
bility in  three  cases  of  movable 
kidney.  The  dotted  lines  show 
limits  of  excursion. 


VI]  MOVABLE    KIDNEY:   SYMPTOMS  83 

behind  the  loin.  The  fingers  of  the  other  hand  are  used  to  palpate 
the  organ.  The  kidney  can  sometimes  be  made  prominent  on  the 
surface  of  the  abdomen  in  this  way,  and  its  outline  distinguished 
with  the  eye. 

Three  grades  of  mobility  of  the  kidney  are  described:  (1) 
where  the  kidney  can  be  readily  grasped  below  the  ribs  ;  (2)  where 
the  fingers  can  be  inserted  above  the  upper  pole ;  (3)  where  the 
kidney  moves  freely  about  the  abdominal  cavity.     (Fig.  22.) 

In  slight  degrees  of  abnormal  mobility  the  kidney  usually  moves 
in  a  line  parallel  with  the  vertebral  column,  but  sometimes  it  swings 


Fig.  23. — Movable  kidney  swinging  on  its  vascular  pedicle. 

round  so  that  the  lower  pole  approaches  the  bodies  of  the  vertebrae. 
The  latter  has  been  called  the  "  cinder  sifting  "  movement  (Morris). 
It  is  difficult  or  even  impossible  to  detect  this  movement  without 
the  help  of  a  general  anaesthetic.  In  another  form  of  abnormal 
movement  the  upper  end  of  the  kidney  falls  forward  while  the  lower 
end  remains  in  contact  with  the  posterior  abdominal  wall.  In  the 
wider  ranges  of  movement  the  kidney  descends  below  the  costal 
margin.  At  first  the  direction  is  vertical,  and  then  the  lower  pole 
swings  towards  the  vertebral  column  at  the  full  length  of  its' vascu- 
lar pedicle,  and  the  hilum,  which  at  first  faces  towards  the  middle 
line,  swings  round  to  face  directly  upwards.    (Fig.  23.)     The  lower 


84  THE   KIDNEY  [chap. 

pole  passes  transversely  and  may  cross  the  middle  line  by  1  or  2  in. 
Finally,  there  are  cases  where  the  vascular  pedicle  is  so  long  that 
it  exerts  no  control  on  the  excursions  of  the  kidney,  and  the 
organ  may  be  found  in  almost  any  part  of  the  abdomen  and  may 
descend  into  the  true  pelvis. 

Where  the  mobility  of  the  kidney  is  marked,  the  organ  is  un- 
influenced by  the  respiratory  movements,  but  many  kidneys  which 
are  abnormally  movable  and  of  which  the  mobility  is  causing 
symptoms  move  with  respiration. 

A  movable  kidney  of  normal  size  presents  the  following  char- 
acters :  The  organ  has  a  smooth,  rounded  surface,  and  the  reniform 
shape  can  frequently  be  detected.  The  tumour  escapes  from 
the  grasp  of  the  fingers  with  a  sudden  slip  that  is  characteristic. 
The  patient  experiences  a  sickening  sensation  when  the  organ  is 
squeezed.  The  tumour  can  be  reduced  into  the  loin,  and  in  this 
position  may  no  longer  be  palpable.  The  kidney  will  usually  drop 
again  when  the  patient  sits  or  stands. 

A  kidney  may  be  found  freely  movable  at  one  examination 
while  at  the  next  it  cannot  be  felt.  It  is  therefore  unwise,  where 
movable  kidney  is  suspected,  to  base  a  negative  diagnosis  on  a 
single  examination. 

(c)  Enlargement  of  the  kidney. — Intermittent  hydronephrosis  is 
an  occasional  result  of  abnormal  mobility.  The  enlargement  of 
the  kidney  may  follow  some  muscular  effort.  In  two  cases  under 
my  care  an  attack  of  pain  and  distension  of  the  kidney  was  in- 
variably brought  on  when  the  patient  was  confined  to  bed.  There 
were  numerous  bands  of  adhesion  between  the  movable  left  kidney 
and  the  descending  colon  in  these  cases,  and  the  obstruction  prob- 
ably resulted  from  the  drag  of  a  loaded  colon.  In  the  earlier 
attacks  the  hydronephrosis  is  small,  but  after  several  attacks  it 
becomes  large  and  forms  a  prominent  swelling  in  the  abdomen. 

After  remaining  for  a  variable  time  the  swelling  disappears 
and  there  is  a  marked  transient  polyuria.  The  hydronephrosis  does 
not  completely  disappear  between  the  attacks  of  acute  distension, 
although  it  is  so  soft  as  to  be  unrecognizable  on  abdominal  palpa- 
tion. A  loose,  partly  filled,  hydronephrotic  sac  will  be  found  on 
operation  in  the  interval  between  attacks  of  acute  distension. 

(d)  Changes  in  the  urine. — Hsematuria  may  occasionally  follow 
muscular  effort  and  be  accompanied  by  attacks  of  pain.  It  is  not 
a  frequent  symptom.  Very  rarely  there  is  moderate  continuous 
hsematuria,  which  ceases  when  the  patient  is  confined  to  bed. 

Albuminuria  is  frequently  observed,  and  disappears  on  resting. 

Tube  casts  may  be  present  in  the  urine.     These  are  due  to 

venous   congestion ;  they   are  present  in   8  out  of    180  cases  of 


vij  MOVABLE   KIDNEY:   SYMPTOMS  «5 

movable  kidney  (Newman).  They  disappear  after  the  operation 
of  nephropexy. 

Transient  polyni'ia  coinci(h'S  with  the  relief  of  an  attack  of 
hydronephrosis.  Anuria  may  result  from  torsion  of  the  renal 
pedicle,  and  has  been  known  to  last  nine  days  without  ill  after- 
effects. Frequent  micturition  may  be  observed  during  an  attack 
of  pain,  and  is  due  to  reflex  impulses  from  the  kidney,  or  it  may 
follow  the  relief  of  a  hydronephrosis,  and  is  due  to  the  increased 
quantity  of  urine. 

2.  Symptoms  referred  to  other  organs. — These  consist  of 
(a)  gastro-intestinal,  (6)  nervous  symptoms. 

{a)  Gastro-intestinal  symptoms  may  be  referred  to  the  stomach. 
There  is  epigastric  pain  and  burning  unconnected  with  taking  food. 
A  sensation  of  sinking  is  complained  of,  and  there  is  loss  of  appetite 
and  nausea.  Eructation,  a  feeling  of  distension  of  the  stomach, 
and  vomiting  are  frequent  symptoms.  In  these  cases  the  stomach 
is  usually  distended,  and  may  be  displaced.  The  patient  becomes 
thin  and  emaciated.  The  right  kidney  is  the  one  which  is  movable 
in  these  cases,  and  the  condition  is  probably  due  to  the  drag  of 
adhesions  on  the  second  portion  of  the  duodenum  (Frank),  or  of 
a  thickened  band  of  peritoneum  upon  the  pylorus  (Bramwell). 

Symptoms  which  are  referred  to  the  large  intestine  are  consti- 
pation and  flatulent  distension  of  the  colon.  The  attacks  are 
recurrent,  and  so  severe  as  to  lead  to  a  suspicion  of  intestinal 
obstruction  from  malignant  growth  or  other  cause.  The  symp- 
toms are  probably  caused  by  adhesions  between  the  kidney  and 
large  intestine. 

Jaundice  may  be  prominent.  There  are  recurrent  attacks  com- 
mencing with  severe  epigastric  pain,  and  the  gall-bladder  may  be 
distended.  These  attacks  cease  after  fixation  of  the  kidney.  They 
have  been  ascribed  to  pressure  of  the  kidney  on  the  common  bile- 
duct,  but  are  more  probably  due  to  dragging  of  the  kidney  upon 
the  second  part  of  the  duodenum. 

(6)  Nervous  symptoms. — A  varying  degree  of  neurasthenia 
accompanies  movable  kidney  in  many  cases.  There  are  depression 
and  irritability,  giddiness,  palpitation,  neuralgic  pains,  loss  of 
appetite,  and  sometimes  loss  of  weight. 

It  is  held  by  Suckhng  that  some  forms  of  insanity  are  due  to 
movable  kidney,  and  are  cured  by  fixation  of  the  organ. 

Acute  attacks,  or  DietVs  crises. — The  patient  suffering  from  mov- 
able kidney  is  liable  to  acute  attacks  or  crises  which  may  be  due 
to  the  kidjuey  dragging  on  the  pylorus  or  bowel  by  adhesions,  or 
to  torsion  of  the  vascular  pedicle,  or  kinking  of  the  ureter.  Such 
an  attack  may  follow  some  muscular  efiort. 


86  THE   KIDNEY  [chap. 

If  the  stomach  or  bowel  is  affected  there  is  epigastric  or  general 
abdominal  pain.  The  patient  lies  with  the  knees  drawn  up,  or  sits 
with  the  thighs  acutely  flexed  on  the  abdomen,  clasping  the  knees 
(Newman).  Vomiting  and  collapse  are  usual.  The  abdominal 
muscles  are  rigid,  and  the  rigidity  may  be  most  marked  on  the  side 
of  the  movable  kidney.  Later  the  abdomen  becomes  distended  and 
tympanitic.  The  stomach  may  be  found  distended,  or  the  colon 
prominent.  The  bowels  are  constipated,  and  the  temperature  may 
be  raised  one  or  two  degrees. 

In  cases  in  which  the  ureter  is  obstructed  there  is  no  distension 
of  the  stomach  or  bowel,  but  on  one  side  of  the  abdomen  a  large 
tender  swelling  rapidly  develops.  The  swelling  has  the  characters 
of  a  renal  tumour.  The  urine  is  diminished,  and  there  may  be 
complete  anuria.  After  lasting  a  few  hours  or  some  days,  the 
swelling  subsides  and  the  symptoms  disappear. 

If  torsion  of  the  renal  vessels  is  the  cause  of  the  crisis  the  symp- 
toms are  again  those  of  an  acute  abdominal  condition.  In  addition 
the  urine  becomes  scanty,  albuminous,  and  sometimes  bloody,  and 
complete  suppression  may  supervene.  The  pain  is  most  severe  in 
the  region  of  one  kidney,  and  this  organ  is  found  to  be  enlarged 
and  tender  if  it  can  be  felt  through  the  rigid  abdominal  muscles. 
When  the  attack  passes  off  the  secretion  of  urine  is  re-established, 
and  polyuria  may  follow.  The  urine  contains  blood,  and  hyaline, 
granular,  and  blood  casts. 

Diagnosis. — The  great  majority  of  cases  of  movable  kidney 
occur  in  patients  of  moderate  or  slight  build,  in  whom  the  abdomen 
is  easily  palpable,  and  the  kidney  readily  felt  and  the  condition 
diagnosed. 

The  following  conditions  may  give  rise  to  difficulty  in  the 
diagnosis  of  a  movable  kidney  : — 

1.  A  distended  gall-hladder. — There  may  have  been  an  attack 
of  jaundice  or  of  haematuria  which  will  point  to  the  swelling  being 
gall-bladder  or  kidney  respectively.  A  distended  gall-bladder  is 
always  palpable,  whereas  a  movable  kidney  sometimes  disappears 
completely.  The  range  of  movement  of  the  gall-bladder  is  more 
restricted.  When  a  movable  kidney  is  reduced  into  the  loin  it 
only  reappears  on  the  patient  breathing  very  deeply  or  sitting 
up.  A  distended  gall-bladder  reappears  whenever  the  pressure  of 
the  examining  fingers  is  removed.  The  kidney  may  be  felt  apart 
from  the  enlarged  gall-bladder.  The  area  of  dullness  over  a  dis- 
tended gall-bladder  is  continuous  with  that  of  the  liver,  and  there 
is  never  bowel  in  front  of  it.     The  two  conditions  may  coexist. 

2.  RiedeCs  lobe  of  the  liver. — The  swelling  moves  with  the  liver 
in  respiration,   and  the   movement    is    greater    than    that   in    a 


VI]  MOVABLE   KIDNEY:    DIAGNOSIS  87 

kidiioy.  The  diilliiess  is  continuous  with  that  ol:  tlie  liver,  and 
the  edge  of  the  swelling  is  sharp.  The  right  lobe  of  the  liver  dragged 
down  by  an  adherent  contracted  gall-bladder  may  resemble  an  en- 
larged movable  kidney.  The  edge  is  hidden  by  adherent  bowel,  but 
there  is  an  absence  of  roundness  of  the  outer  border  and  lower  pole. 
I  have  had  a  case  of  splenic  leukaemia  with  enlarged  spleen  and 
liver  referred  to  me  as  a  case  of  bilateral  movable  kidney  wdth 
anaemia. 

3.  A  small  ovarian  tumour  with  a  long  pedicle. — The  tumour 
can  be  reduced  into  the  pelvis,  but  not  into  the  loin.  Careful 
examination  will  usually  show  that  the  pedicle  of  the  ovarian  cyst 
is  attached  below.  Vaginal  examination  may  demonstrate  the 
pelvic  attachment  of  the  swelling. 

4.  A  malignant  growth  of  the  large  intestine  may  simulate  a 
movable  kidney.  If  may  be  possible  to  reduce  the  swelling  into 
the  loin  in  a  manner  similar  to  a  movable  kidney.  Symptoms  of 
intestinal  obstruction  are  occasionally  produced  by  a  movable 
kidney,  and  this  makes  the  diagnosis  more  difficult.  A  prolonged 
history  of  intestinal  disturbance  and  the  absence  of  urinary  symp- 
toms will  point  to  a  tumour  of  the  bowel. 

Where  difficulty  arises  as  to  the  nature  of  a  swelhng  in  the  region 
of  the  kidney,  the  introduction  of  collargol  into  the  renal  pelvis 
through  a  ureteric  catheter,  followed  by  radiography  (pyelography), 
should  be  used  to  show  the  position  of  the  renal  pehas  and  calyces. 
By  this  means  the  relation  of  the  kidney  to  the  tumour  will  be 
demonstrated.  (Plate  2,  Fig.  3.)  Radiography  after  a  bismuth 
meal  will  further  demonstrate  the  relation  of  the  intestine  to  the 
tumour. 

While  the  recognition  of  a  movable  kidney  is  essential  for  the 
diagnosis,  and  a  movable  kidney  is  frequently  the  cause  of  symp- 
toms which  are  referred  to  other  organs,  it  does  not  follow  that 
where  symptoms  such  as  neurasthenia  are  present  with  a  movable 
kidney  the  nervous  symptoms  result  from  the  renal  mobility.  If 
the  neurasthenia  is  known  to  have  been  present  before  the  kidney 
became  movable,  and  if  the  replacement  of  the  kidney  and  its 
retention  by  lying  in  bed  or  the  application  of  some  mechanical 
support  have  no  effect  in  allaying  the  symptoms,  it  is  likely  that 
the  two  conditions  are  independent.  But  if  movement  aggravates 
the  symptoms  and  rest  or  support  affords  relief,  there  is  a  relation 
of  cause  and  effect  between  the  undue  mobility  of  the  kidney  and 
the  neurasthenia. 

Treatment.  Selection  of  cases. — The  careful  selection  of 
cases  for  the  different  methods  of  treatment  is  the  only  means  of 
obtaining  satisfactory  results.     In  cases  where  no  symptoms  are 


88  THE   KIDNEY  [chap. 

present  and  there  does  not  appear  to  be  any  change  taking  place 
in  the  kidney  itself,  as  shown  by  enlargement  or  tenderness  of  the 
organ  or  changes  in  the  urine,  it  will  only  be  necessary  to  limit 
violent  exercises,  such  as  horse-riding,  and  to  warn  against  lifting 
heavy  weights.  The  bowels  should  be  carefully  regulated.  Should 
symptoms  appear,  active  treatment  of  the  mobility  will  become 
necessary.  In  such  cases  a  choice  will  have  to  be  made  between 
palliative  and  operative  treatment. 

In  certain  cases  'palliative  treatment  is  contra-indicated  and 
operative  treatment  is  imperative  : 

1.  Where  there  are  signs  that  the  mobihty  is  causing  disease 
of  the  kidney.  This  includes  cases  in  which  the  kidney  is  tender 
or  enlarged,  cases  of  intermittent  hydronephrosis,  cases  in  which 
heematuria  or  albuminuria  is  present,  or  there  are  tube  casts  in  the 
urine,  or  slight  or  severe  attacks  of  torsion  of  the  renal  pedicle 
have  occurred. 

2.  Where  the  kidney  is  exerting  harmful  traction  upon  other 
organs.  This  includes  cases  where  there  are  gastric  and  intestinal 
crises  and  attacks  of  jaundice. 

3.  Where  the  kidney  lies  below  the  waist  line  and  is  uncon- 
trolled by  any  mechanical  apparatus,  and  the  use  of  a  mechanical 
apparatus  causes  pain  and  aggravates  the  symptoms. 

4.  Where  the  patient  is  going  to  reside  in  tropical  or  uncivilized 
countries. 

5.  Where  the  patient  has  to  perform  manual  labour,  and  the 
expense  of  maintaining  an  apparatus  in  good  order  cannot  be 
borne. 

In  all  other  cases  palHative  treatment  may  be  tried  before 
resorting  to  operation. 

In  certain  cases  operative  treatment  is  contra-indicated,  because 
doomed  to  failure  : 

Where  general  enteroptosis  is  present. 

Where  severe  neurasthenia  is  present  and  no  symptoms  can 
be  referred  to  the  kidney. 

In  a  few  cases  of  movable  kidney  with  neurasthenia,  control  of 
the  renal  movements  by  a  mechanical  apparatus  will  alleviate  or 
cure  the  neurasthenia,  and  in  these  cases  also  fixation  of  the  kidney 
by  operation  will  be  followed  by  a  similar  result.  This  view  is 
generally  held,  but  a  few  writers  go  further  and  advocate  operation 
in  all  cases  of  neurasthenia  with  movable  kidney. 

Palliative  treatment.  1.  Treatment  by  rest  and  in- 
creasing the  body  fat. — It  is  claimed  by  a  very  few  writers  that 
this  method  can  bring  about  a  cure  of  the  renal  mobility.  They 
hope  by  increasing  the  general  fat  of  the  body  to  produce  a  simulta- 


vi]  MOVABLE   KIDNEY:   TREATMENT  89 

.iieous  deposit  around  the  kidney,  which  will  fix  it  in  ]josition.  Such 
a  result  is  not  obtained  in  practice.  The  method  is,  hcnvever, 
useful  in  treating  cases  of  movable  kidney  in  which  neurasthenic 
symptoms  are  present.  In  these  cases  a  "  rest  cure  "  should  be 
the  first  resort  and  an  operation  the  last. 

The  patient  is  strictly  confined  to  bed,  and  in  severe  cases  full 
Weir-Mitchell  isolation  should  be  exacted.  The  bowels  are  care- 
fully regulated,  and  the  food  is  chosen  with  the  view  of  increasing 
the  bocly-weight.  Milk  is  given  in  large  quantities,  graduated 
according  to  the  digestive  powers.  General  massage  is  adminis- 
tered, but  the  kidney  areas  are  not  subjected  to  manipulation. 
The  treatment  extends  over  a  month  or  six  weeks. 

This  is  a  useful  preliminary  to  treatment  by  means  of  mechani- 
cal apparatus. 

2.  Treatment  by  mechanical  apparatus. — Treatment  by 
this  means  is  especially  indicated  when  enteroptosis  is  present.  It 
is  suitable  for  any  case  of  movable  kidney,  with  the  exceptions 
already  mentioned. 

Three  forms  of  apparatus  will  be  described  : 

{a)  Kidney  truss. — The  truss  made  by  Ernst  consists  of  a  thin, 
carefully  padded  metal  plate  which  exercises  pressure  upon  the 
abdominal  wall  by  means  of  two  springs.  The  pressure  concerns 
the  lower  and  inner  margins  of  the  plate,  so  that  the  kidney  is 
forced  upwards  and  outwards.  It  must  of  necessity  be  applied 
when  the  patient  is  lying  down.  The  truss  must  be  very  carefully 
fitted,  and  the  patient  trained  and  practised  in  its  proper  adjust- 
ment.    She  is  able  to  take  active  exercise. 

(6)  Kidney  belt. — A  kidney  belt  is  an  abdominal  belt  which  is 
specially  adapted  for  the  relief  of  movable  kidney.  It  consists  of 
a  broad  band  of  jean  or  coutil  which  surrounds  the  waist  and 
comes  down  over  the  iliac  crests  and  is  accurately  moulded  to 
the  hips.  The  lower  border  follows  the  curve  of  the  groin  along 
Poupart's  hgament,  and  in  the  middle  line  in  front  it  slightly 
overlaps  the  pubic  bones.  The  upper  border  is  about  the  level 
of  the  umbilicus.  The  belt  is  stiffened  by  whalebone  or  light 
steel  busks.  It  is  laced  in  front  and  behind.  At  each  side  there 
is  a  broad  inset  of  silk  elastic.  There  are  two  perineal  straps  to 
prevent  the  belt  from  riding  upwards. 

A  kidney  pad  is  added  with  the  view  of  exerting  pressure  upon 
the  movable  kidney  and  retaining  it  in  place.  This  may  be  horse- 
shoe-shaped or  oval.  The  pad  may  be  fixed  in  the  lining  of  the 
belt,  and  consists  of  a  rubber  bag  with  a  fine  tube  which  pierces 
the  belt  and  has  a  turncock.  Or  it  may  be  a  closed  air  sac  or 
rubber  bag  containing  glycerine,  which  fits  into  a  pocket  in  the 


90  THE   KIDNEY  [chap. 

lining  of  the  belt.  The  belt  must  be  put  on  when  the  patient  is 
recumbent,  and  is  worn  over  a  silk  or  fine  woollen  under- vest. 

A  belt  of  similar  construction  can  be  fitted  to  the  lower  part 
of  a  corset,  and  by  this  means  the  perineal  straps,  which  are 
irksome,  become  unnecessary. 

The  pads  which  are  used  in  these  belts  do  not  control  the  move- 
ments of  the  kidney  ;  were  they  sufficiently  large  and  firm  to  do 
so  they  would  exert  injurious  pressure  upon  the  bowel.  Their  use 
appears,  however,  to  give  a  feeling  of  security  to  the  wearer,  and 
for  this  reason  they  may  be  worn. 

(c)  Corset  for  movable  kidney  {Gallant). — The  corset  is  made 
from  measurements  taken  from  the  patient.  At  the  bottom  the 
front  steels  must  overlap  the  upper  half-inch  of  the  symphysis 
pubis  and  fit  very  snugly  over  the  hips,  stretching  tightly  from 
one  to  the  other  to  flatten  and  reduce  the  hypogastrium.  The 
circumference  must  be  equal  to  the  natural  waist,  but  there  should 
be  well-marked  incurving  of  the  sides,  so  that  the  clothing  is 
supported,  the  corset  prevented  from  slipping  upwards,  and  a 
fashionable  outUne  afforded  to  the  figure.  At  the  back  and  sides 
the  upper  portion  must  accurately  fit  the  thorax,  while  in  front 
ample  room  must  be  provided  for  the  replaced  stomach.  Below 
the  waist  the  corset  must  be  inflexible  and  inelastic,  and  the 
portion  above  the  waist  must  permit  free  play  to  the  trunk  and 
thoracic  walls. 

If  the  hips  are  poorly  developed,  pads  should  be  stitched  inside 
the  lower  part  of  the  corset  to  give  rotundity  to  the  figure  and 
avoid  painful  pressure  on  the  iliac  crests  and  anterior  spines. 

One  lace  begins  at  the  eyelet  above  the  waist  line,  and  is  con- 
tinued down  to  the  bottom  of  the  corset.  In  the  upper  part  a 
thin,  flat  hat-elastic  is  loosely  threaded,  so  as  to  keep  the  corset 
in  contact  with  the  thorax  but  not  to  cause  pressure. 

The  following  directions  must  be  followed  in  putting  on  the 
corset  : 

The  lower  lacing  is  freely  loosened  and  the  corset  applied  to 
the  body  over  a  fine  woollen  or  silk  vest. 

The  patient  lies  on  her  back  on  a  bed,  and  the  legs  are  flexed 
to  a  right  angle. 

The  abdomen  is  massaged,  by  stroking  upwards,  for  ten 
minutes.  The  corset  is  then  drawn  well  down  over  the  hips  and 
fastened  in  front,  beginning  with  the  lowest  hook.  Without  lower- 
ing the  thighs  the  lace  behind  is  drawn  as  tight  as  possible  and 
tied.  The  corset  must  not  be  drawn  down  after  the  front  has 
been  fastened. 

The  lower  part  above  the  pubes  must  flt  so  snugly  that  the 


VI]  NEPHROPEXY  91 

fingers  can  barely  be  inserted  between  the  corset  and  the  piibes 
when  the  patient  is  lying  down.  On  rising,  sitting,  or  walking  the 
corset  should  not  slip  upwards. 

Uallant  holds  that  from  90  to  95  per  cent,  of  movable  kidneys 
with  symptoms  are  cured  of  the  symptoms  by  wearing  this  corset. 

Operative  treatment. — The  preparation  of  the  patient  is 
similar  to  that  in  other  kidney  operations.  The  position  depends 
upon  the  incision  employed :  for  the  oblique  posterior  incision 
the  patient  lies  on  the  side  with  a  pillow  beneath  the  loin ;  for  the 
vertical  posterior  incision  she  lies  prone  with  an  air  pillow  beneath 
the  abdomen ;  and  for  the  anterior  incision  the  dorsal  position  is 
adopted. 

1.  The  incision. — The  usual  incision  is  the  oblique  posterior, 
passing  downwards  and  forwards  from  the  angle  formed  by  the 
last  rib  and  the  erector  spinse  mass  of  muscle  for  4  or  6  in.  The 
advantage  of  this  incision  is  the  good  exposure  and  the  possi- 
bility of  unlimited  extension.  In  it  the  latissimus  dorsi  and  the 
three  layers  of  abdominal  muscles  and  the  lumbar  aponeurosis 
are  cut. 

A  vertical  posterior  incision  along  the  outer  border  of  the 
erector  spinse  muscle  is  used  by  Edebohls.  The  latissimus  dorsi 
is  pushed  aside,  and  the  external  oblique  pulled  forwards.  The 
lumbar  aponeurosis  is  split  vertically.  The  advantage  of  this 
incision  is  the  slight  disturbance  of  muscles.  A  disadvantage  is 
that  the  exposure  is  limited. 

An  anterior  incision  has  been  used  by  some  surgeons  (Harlan, 
Stanmore  Bishop,  Watson  Cheyne).  It  runs  from  the  anterior  edge 
of  the  latissimus  dorsi  forwards  for  4  in.  parallel  with  the  costal 
margin.  Stanmore  Bishop  opened  the  peritoneal  cavity ;  Watson 
Cheyne  pushes  the  peritoneum  inwards  and  exposes  the  front  of 
the  kidney.  This  incision  is  less  suitable  for  dealing  with  disease 
of  the  kidney  which  may  accompany  the  undue  mobihty.  The 
advantage  claimed  for  it  is  that  it  allows  of  the  kidney  being 
replaced  and  fixed  in  its  normal  position,  whereas  the  posterior 
incision  necessitates  the  fixation  in  an  abnormal  position. 

2.  Removal  of  the  fatty  capsule. — All  authorities  are  agreed 
that  the  adipose  tissue  immediately  surrounding  the  kidney  should 
be  carefully  removed.  The  perirenal  fat,  the  posterior  layer  of 
perirenal  fascia,  and  the  fat  between  this  and  the  quadratus  Imn- 
borum  and  psoas  muscles  must  be  dissected  away,  and  the  muscles 
laid  bare.  This  can  only  be  carried  out  satisfactorily  through  a 
free  incision. 

3.  Methods  of  fixation. — i.  By  sutures  passing  through  the 
kidney  capsule  or  kidney  substance.     The  suture  material  may  be 


92  THE   KIDNEY  [chap. 

catgut,  silk,  kangaroo  tendon,  or  a  strip  of  tendon  from  the  erector 
spinse  muscle  of  the  patient  left  attached  at  one  end.  Strong 
catgut  and  kangaroo  tendon  are  the  best  of  these. 

If  the  suture  is  to  be  passed  through  the  capsule  alone,  a  small 
slit  is  made  in  it  and  a  director  passed  along  underneath,  stripping 
it  up  for  a  varying  distance  and  ending  at  a  second  small  slit. 
The  suture  material  is  threaded  along  this  tunnel  and  passed  through 
the  muscles  of  the  abdominal  wall.  Several  such  sutures  may  be 
passed,  and  they  may  be  placed  at  the  convex  border  of  the  kidney 
or  on  the  posterior  surface.  The  sutures  may  be  passed  through 
the  kidney  substance  about  |  in.  from  the  convex  border,  and  then 
through  the  muscles  of  the  abdominal  wall  at  the  upper  edge  of 
the  wound. 

ii.  By  stripping  the  capsule  of  the  kidney  (decortication).  An 
incision  through  the  fibrous  capsule  of  the  kidney  is  made  along 
the  convex  border,  and  the  capsule  seized  with  dissecting  forceps 
and  stripped  from  both  surfaces  as  far  as  the  hilum,  where  it  is 
clipped  away.  This  is  done  with  the  view  to  producing  adhesions 
between  the  stripped  surface  of  the  kidney  and  the  surrounding 
structures. 

iii.  By  stitching  the  stripped  capsule  to  the  parietes.  Many 
variations  of  this  method  have  been  introduced.  The  stripped 
capsule  may  be  rolled  up  on  the  anterior  and  posterior  surfaces  of 
the  kidney  without  carrying  it  as  far  as  the  hilum,  and  stitches 
introduced  through  the  rolled  capsule  and  the  muscles  of  the 
abdominal  wall.  The  capsule  may  be  stripped  in  a  number  of 
wedges,  each  of  which  is  stitched  to  the  abdominal  wall.  The 
kidney  may  be  slung  by  passing  a  strip  of  capsule  through  a  slit 
in  the  ligamentum  arcuatum  externum  (Foulerton). 

iv.  By  partial  stripping  and  suture  through  the  substance  of 
the  kidney.  It  may  be  necessary  to  explore  the  kidney,  and  the 
incision  is  placed  along  the  convex  border  of  the  kidney.  The 
nephrotomy  wound  is  closed  by  four  or  five  thick  catgut  sutures 
passed  through  the  kidney  substance.  These  are  tied  and  left  long. 
An  elliptical  incision  through  the  fibrous  capsule  leaves  an  area  of 
unstripped  capsule,  which  contains  the  nephrotomy  incision  and 
the  sutures  closing  it.  The  capsule  is  stripped  from  the  anterior 
and  posterior  surfaces  of  the  kidney.  The  ends  of  the  catgut 
sutures  are  passed  through  the  upper  and  lower  muscular  edges  of 
the  wound,  and  are  tied  after  the  wound  has  been  closed.  Or  the 
highest  suture  is  passed  through  the  muscles  of  the  last  intercostal 
space  and  tied. 

V.  By  methods  designed  to  promote  granulation.  Long  strips 
of  gauze  are  placed  below  the  lower  pole  of  the  kidney  to  promote 


VlJ 


NEPHROPEXY 


93 


granulation  and  the  formation  of  a  fibrous  sling  to  support  the 
kidney  (Jaboulay). 

vi.  The  formation  of  a  shelf  of  peritoneum  or  fibrous  capsule. 
Stanmore  Bishop  opened  the  peritoneal  cavity  by  an  anterior  incision 
and  replaced  the  kidney  in  its  proper  position.  The  peritoneum 
covering  the  lower  third  of  the  kidney  was  divided  transversely,  and 
the  capsule  stripped  downwards  and  inwards  from  the  anterior 
surface  of  this  portion  of  the  kidney.  The  divided  peritoneum  was 
replaced  and  sutured.  Sutures  were  passed  directly  backwards 
through  the  peritoneum,  detached  capsule,  and  posterior  abdominal 


Fig.  24. — Method  of  fixation  of  kidney. 

The  kidney  has  been  delivered  from  the  lumbar  wound  and  its  posterior  surface  decapsulated. 

Three  catgut  sutures  (A,  A')  are  passed  through  the  substance  of  the  organ.     B,  Last  rib  ; 

C,  quadratus  lumborum  muscle. 

wall,  so  as  to  form  a  chain  of  sutures  extending  from  immediately 
below  the  renal  pelvis  along  the  internal  and  inferior  edge  of  the 
kidney  and  a  short  distance  round  the  external  edge.  The  sutures 
were  tied  behind  after  division  of  the  skin  and  subcutaneous  fat 
over  the  muscular  layer. 

Watson  Cheyne  exposes  the  kidney  by  an  anterior  incision 
and  pushes  aside  the  peritonemn.  The  muscles  of  the  posterior 
abdominal  wall  are  cleared  of  fat.  The  fibrous  capsule  is  stripped 
from  the  posterior  surface  of  the  lower  pole  of  the  kidney,  and 
another  flap  of  capsule  from  the  outer  half  of  the  remaining  part 
of  the  posterior  surface,  and  the  capsule  is  stripped  as  far  as  the 


94 


THE  KIDNEY 


[chap. 


convex  border.  The  kidney  is  replaced,  and  the  flaps  of  the  cap- 
sule are  stitched  down  to  the  muscles  of  the  posterior  abdominal 
wall,  so  that  the  raw  surface  is  kept  in  contact  with  the  muscles. 
I  use  a  free  oblique  lumbar  incision,  and  prepare  the  posterior 
abdominal  wall  carefully  by  dissection  of  the  fascia  and  fat.  Only 
the  posterior  surface  of  the  kidney  is  stripped  of  capsule,  as  it  is 
undesirable  that  the  anterior  surface  should  become  adherent  to 
the  colon.  Three  catgut  stitches  are  passed  through  the  kidney  an 
inch  from  its  convex  border.  The  upper  suture  is  passed  through 
the  intercostal  muscles  ^of  the  last  space,  and  the  lower  two  are 


Fig.  25. — Method  of  fixation  of  kidney. 

The  upper  suture  is  passed  through  the  last  intercostal  space,  the  other  through  the  quadratus 
lumborum  muscle.     A,  A',  Catgut  sutures  ;  B,  last  rib  ;  C,  quadratus  lumborum  muscle. 

passed    through    the    outer    edge    of    the    quadratus    lumborum. 
(Figs.  24,  25.)     The  patient  is  confined  to  bed  for  four  weeks. 

Results. — The  operative  mortality  is  stated  at  1  per  cent., 
but  it  is  lower  than  this  in  the  practice  of  most  surgeons.  The 
statistics  in  regard  to  the  success  of  operation  vary.  Keen  found 
that  of  116  cases  examined  not  less  than  three  months  after 
operation  57-8  per  cent,  were  cured,  12-9  per  cent,  improved, 
and  in  19-8  per  cent,  the  operation  failed.  Failure  may  consist 
in  recurrence  of  the  mobility  or  the  persistence  of  pain.  Of  42 
cases  examined  by  Mc Williams,  22  were  cured,  8  greatly  benefited, 
7  somewhat  reheved,  and  5  unrelieved  of  symptoms.  Improvement 
in  many  cases  was  only  seen  some  months  after  the  operation. 


vij  RESULTS  OF  NEPHROPEXY  95 

There  were  48  per  cent,  of  cures  where  parenchymatous  sutures 
were  used,  and  52  per  cent,  of  cures  where  no  parenchymatous 
sutures  were  employed. 

Wilson  and  Howell  examined  41  cases  after  nephropexy  had 
been  performed  at  St.  Bartholomew's  Hospital,  and  found  12 
cured,  8  greatly  improved,  12  improved,  and  9  unaffected  by  the 
operation. 

Failures,  are,  I  believe,  due  to  incomplete  removal  of  fat,  want 
of  stripping  of  the  kidney,  tearing  out  of  sutures  too  tightly  tied, 
and  too  short  confinement  to  bed.  It  is  immaterial  whether  the 
kidney  is  fixed  in  normal  position  or  lower  down,  so  long  as  the 
pedicle  and  ureter  are  not  twisted. 

LITERATURE    • 

Barling,  Brit.  Med.  Journ.,  1908,  i.  972. 

Billington,  Brit.  Med.  Journ.,  May  1,  1909. 

Bishop,  Stanmore,  Lancet,  July  6,  1907,  vol.  ii. 

Cheyne,  Watson,  Lancet,  April  24,  1909. 

Gallant,  Journ.   Amer.  Med.  Assoc,  Nov.  7,  1908. 

Glenard,  Les  Ptoses  Viscerales.     Paris,  1899. 

Guiteras,  New  York  Med.  Bee,  1903,  p.  561. 

Keen,  A^m.  Surg.,  Aug.,  1890. 

Lane,  Arbuthnot,  Lancet,  Jan.  17,  1903. 

M.QTT\S,  Surgical  Diseases  of  the  Kidney  and  Ureter.     1901. 

Moullin,  Mansell,  Brit.  Med.  Journ.,  March  10,  1900. 

Newman,  Movable  Kidney.     1907. 

Treves,  PracL,  Jan.,  1905. 

Walker,  Thomson,  Lancet,  Aug.  11,  1906. 

Walkow  und  Delitzen,  Die  Wandemierc.     Berlin,  1899 

Wilson  and  Howell,  Movable   Kidney.     1909. 


CHAPTER  VII 
INJURIES    TO    THE    KIDNEY 

I.   WITHOUT   EXTERNAL   WOUND 

The  kidney  is  well  protected  by  the  lower  ribs  and  the  spinal 
muscles,  and  injuries  of  this  organ  are  comparatively  rare.  In 
7,741  injuries  found  post  mortsm,  10  (0-12  per  cent.)  were  injuries 
of  the  kidney,  and  in  only  one  of  these  was  there  an  open  wound. 
The  relation  of  injuries  to  surgical  diseases  of  the  kidney  is  7-81  per 
cent.  (Kiister). 

The  right  side  is  more  frequently  affected  than  the  left,  and 
the  injury  is  rarely  bilateral  (142  right,  118  left,  12  bilateral).  The 
usual  age  is  from  10  to  30  years.  There  is  a  great  preponderance 
of  male  subjects.  Of  299  cases,  281  (93-9  per  cent.)  were  male  and 
18  (6-1  per  cent.)  were  female. 

Etiology. — The  form  of  injury  which  produces  the  rupture 
may  be  a  direct  blow  on  the  loin  or  over  the  lower  ribs,  such  as  a 
kick  or  a  fall  across  a  beam  or  cart-wheel,  or  the  passage  of  a  wheel 
over  the  loin,  or  compression  between  buffers ;  or  the  violence  may 
be  indirect,  such  as  a  fall  from  a  height  on  the  buttocks  or  forcible 
acute  flexion  of  the  body.  In  these  cases  of  indirect  violence 
Tuffier  holds  that  the  kidney  is  injured  by  impact  against  the  12th 
rib  or  the  transverse  process  of  the  1st  lumbar  vertebra. 

In  cases  where  the  body  is  acutely  flexed  from  a  fall  or  muscular 
exertion  the  laceration  of  the  kidney  arises  from  flexion  on  its 
transverse  axis. 

Kiister  ascribes  an  important  role  to  hydrostatic  pressure  within 
the  kidney  in  the  production  of  laceration.  He  experimented  by 
distending  the  veins,  arteries,  and  renal  pelvis,  and  applying  vio- 
lence to  the  surface  of  the  organ,  and  produced  deep  transverse 
lacerations  which  extended  into  the  pelvis. 

The  part  of  the  kidney  adjacent  to  the  hilum  is  that  most 
frequently  torn.  The  most  friable  part  of  the  kidney  substance  is 
at  the  junction  of  the  cortex  and  medulla.  The  mobility  of  the 
kidney  is  some  protection  against  rupture. 

Pathology.     1-   Lesions    of   the    kidney. — The  fatty  capsule 

96 


CHAP,  viij  RENAL  INJURIES  97 

alone  may  be  torn,  without  injury  to  the  renal  parenchyma.  Around 
the  kidney  there  is  an  accumulation  of  blood,  which  later  becomes 
organized  and  eventually  constitutes  a  layer  of  fibrous  tissue. 
Less  frequently  a  cyst  containing  blood  is  formed.  From  a  slight 
subcapsular  rupture  of  the  kidney,  blood  may  be  poured  out  and 
accumulate  beneath  the  fibrous  capsule  of  the  organ. 

In  a  more  severe  degree  the  fibrous  capsule  is  ruptured  and  there 
is  extravasation  of  blood  in  the  substance  of  the  kidney,  especially 
at  the  base  of  the  pyramids,  and  at  the  same  time  blood  is  effused 
into  the  renal  pelvis.  The  lacerations  are  usually  transverse  or 
slightly  oblique,  and  radiate  from  the  hilum.  There  is  commonly 
one  large  tear  with  several  smaller  lacerations,  and  there  is  always 
bruising  of  the  parenchyma  in  the  neighbourhood.  Lacerations  are 
more  frequent  on  the  anterior  than  on  the  posterior  surface  of  the 
kidney,  and  at  the  lower  than  at  the  upper  pole. 

In  severe  degrees  of  rupture  the  rent  passes  from  the  surface 
to  the  pelvis  in  a  transverse  or  oblique  direction.  The  whole  of 
one  pole  of  the  kidney  may  be  detached.  The  kidney  may  be 
broken  up  into  several  fragments  and  the  substance  pulped.  Some- 
times a  large  branch  of  the  renal  artery  is  ruptured,  and  the  ureter 
may  be  torn. 

Earely  the  organ  may  be  split  along  its  convex  border,  or  it 
may  be  torn  from  its  pelvis  and  vessels. 

When  the  kidney  is  ruptured,  blood  is  poured  out  and  collects 
in  considerable  quantity  within  the  fatty  capsule.  With  extensive 
laceration  and  pulping  of  the  kidney  there  is  sometimes  compara- 
tively little  effusion  of  blood.  The  blood  may  track  along  the 
spermatic  vein  and  cause  discoloration  of  the  skin  at  the  external 
abdominal  ring,  and  of  the  scrotum  or  labium. 

In  most  cases  there  is  laceration  of  the  renal  pelvis  or  of  a 
calyx,  so  that  urine  is  mixed  with  the  effused  blood.  A  large 
collection  of  urine  and  blood  may  be  formed  which  becomes  limited 
by  adhesions  (pseudo-hydronephrosis). 

Blood  is  also  poured  into  the  renal  pelvis  and  passes  into  the 
bladder.  The  ureter  may  be  ruptured  or  a  clot  may  block  its 
lumen,  so  that  no  blood  reaches  the  bladder. 

2.  Lesions  of  other  organs. — Rupture  of  the  kidney  is  fre- 
quently complicated  by  other  lesions.  The  peritoneum  may  be 
torn,  when  blood  and  urine  are  poured  into  the  peritoneal  cavity. 
This  happens  more  frequently  in  children  than  in  adults,  since 
the  perinephritic  fat  is  not  developed  before  the  tenth  year,  and 
the  peritoneum  is  therefore  in  more  intimate  relation  with  the 
kidney  up  to  that  age.  Fracture  of  one  or  more  ribs  occurs  in 
5  per  cent,  of  cases  (Tuffier).     The  spinal  column  may  be  injured, 

H 


98  THE   KIDNEY  [chap. 

and  the  pelvic  girdle  is  occasionally  fractured  (2  per  cent.).    There 
may  be  injuries  to  the  bowel,  liver,  spleen,  bladder,  and  lungs. 

In  36  post-mortem  examinations  of  subcutaneous  renal  lesions 
Giiterbock  found  fracture  of  the  ribs  in  21,  laceration  of  the  liver 
in  20,  of  the  spleen  in  13,  of  the  suprarenal  capsule  in  9,  and  of 
the  bowel  and  mesentery  in  3. 

Repair. — In  the  slighter  degrees  of  rupture  the  process  of 
repair  takes  place  very  rapidly.  A  clot  forms  between  the  edges 
of  the  wound,  and  the  surrounding  parenchyma  is  infiltrated  with 
blood  lying  between  and  within  the  tubules.  In  this  zone  the 
epithelium  of  the  tubules  degenerates,  the  area  thus  affected  taking 
the  wedge  shape  of  an  infarct  with  the  broadest  part  at  the  surface 
of  the  kidney.  Outside  this  area  there  is  a  zone  where  the  inter- 
tubular  connective  tissue  proliferates,  and  the  round-cell  infiltration 
thus  produced  invades  the  clot  and  eventually  forms  fibrous  tissue. 
The  tubules  nearest  the  edge  of  the  wound  degenerate  and  are 
hidden  by  the  round-cell  infiltration.  In  the  less  damaged  tissues 
regeneration  of  the  damaged  epithelium  takes  place,  but  there  is 
no  new  formation  of  tubules.  The  glomeruli  atrophy  slowly,  and 
persist  for  a  long  time  in  the  cicatrix. 

The  wound  in  the  kidney  may  be  firmly  healed  in  three  weeks. 
Occasionally  healing  may  be  delayed  for  many  months,  and  debris 
and  clots  are  found  in  the  wound  with  little  attempt  at  cicatrization. 
Wounds  of  the  renal  pelvis  leave  a  fibrous  scar  which  does  not 
cause  narrowing  of  the  receptacle.  Occasionally  a  fistula  remains, 
and  if  this  heals  there  is  pocketing  in  the  interior  of  the  renal  pelvis. 
When  the  kidney  has  been  extensively  lacerated  and  pulped  the 
whole  organ  may  be  converted  into  a  fibrous  mass  in  which  little 
kidney  tissue  remains.  The  blood  which  was  effused  is  either 
absorbed  (rarely  it  remains  as  a  cyst),  or  it  may  become  infected 
and  suppuration  occur. 

Infection  and  suppuration  in  the  form  of  perinephritic  abscess, 
suppurative  nephritis,  pyonephrosis,  and  peritonitis  occur  in  11 '8 
per  cent,  of  cases. 

Symptoms. — Shock  is  present  to  a  varying  degree  in  all  the 
more  severe  grades  of  rupture. 

The  symptoms  may  not  appear  immediately  on  receipt  of  the 
injury.  I  have  seen  a  gamekeeper  fall  heavily  on  his  shoulder 
while  dragging  a  shot  stag  down  a  steep  hillside,  pick  himself  up, 
resume  his  part  in  dragging  the  animal  for  another  mile,  and 
then  take  his  turn  in  trundling  the  16-stone  weight  in  a  wheel- 
barrow for  another  mile  and  a  half.  There  were  no  signs  during 
that  evening  or  throughout  the  night,  but  next  morning  he  noticed 
blood  in  his  urine  and  then  became  faint.     When  I  saw  him  he  was 


VII]  RENAL  INJURIES  99 

pale  and  sweating,  with  a  rapid,  feeble  pulse  and  a  drawn,  anxious 
face,  and  he  had  been  sick.  He  passed  a  large  quantity  of  blood, 
and  the  hsematuria  continued  for  a  week.  There  was  tenderness 
over  the  left  kidney  with  rigidity  of  the  abdominal  muscles  on  this 
side.     He  made  a  good  recovery. 

The  symptoms  which  are  characteristic  of  rupture  of  the  kidney 
are  pain,  tumour,  haematuria,  and  variations  in  the  quantity  of  urine. 

Pain. — Pain  after  an  injury  to  the  loin  may  result  from  the 
bruising  of  the  tissues,  or  it  may  be  due  to  fracture  of  the  ribs. 
The  pain  which  points  to  an  injury  of  the  kidney  radiates  along 
the  line  of  the  ureter  and  is  accompanied  by  retraction  of  the  testicle. 
This  pain  is  severe,  and  is  present  especially  when  the  haemorrhage 
is  copious  and  clots  are  passed  down  the  ureter.  There  is  also  a 
dull  heavy  pain,  deeply  seated  in  the  loin,  which  is  increased  by 
palpation,  by  movement,  coughing  or  sneezing. 

The  abdominal  muscles  are  rigidly  contracted,  and  palpation 
of  the  loin  is  difficult  and  painful. 

The  pain  may  last  for  a  week  or  more. 

Tumour. — Even  in  slight  lacerations  of  the  kidney  there  may 
be  perirenal  swelling.  When  a  large  quantity  of  blood  and  urine 
is  effused  it  forms  a  prominent  swelling  in  the  loin,  which  may 
be  found  soon  after  the  injury,  or  its  appearance  may  be  delayed 
for  some  days.  The  swelling  is  dull  on  percussion  and  very  tender 
on  palpation,  and  may  be  slightly  movable.  It  is  usually  diffuse 
and  obscured  by  the  rigidity  of  the  abdominal  muscles  or  distension 
of  the  bowel  (pseudo-hydro-hsematonephrosis). 

If  the  swelling  be  smooth  and  clearly  outlined  and  ballottement 
can  be  obtained  the  renal  pelvis  has  been  distended  with  blood 
and  a  haematonephrosis  formed.     The  condition  is  very  rare. 

Haematuria. — There  is  blood  in  the  urine  in  nearly  all  cases  of 
rupture  of  the  kidney  (91-5  per  cent.).  In  shght  cases  it  may  be 
the  only  symptom. 

Haematuria  may  be  absent  in  cases  of  shght  cortical  rupture 
when  the  injury  does  not  affect  the  renal  pelvis,  or  it  may  fail  to 
appear  when  the  kidney  is  completely  pulped  and  the  ureter  torn 
across,  or  when  the  ureter  is  blocked  with  clot.  In  slight  injuries 
the  microscope  may  be  required  to  detect  the  blood.  In  other 
cases  the  first  urine  passed  after  the  accident  is  blood-stained,  and 
then  the  bleeding  ceases. 

In  severe  cases  blood  is  present  in  large  quantity.  It  usually 
appears  immediately  after  the  injury,  but  it  has  sometimes  been 
delayed  for  several  days. 

In  about  50  per  cent,  of  cases  the  haematuria  has  disappeared 
in  a  week ;    in  other  cases  it  persists  for  several  weeks,  and  may 


100  THE   KIDNEY  [chap. 

be  the  cause  of  death  at  the  end  of  a  fortnight  or  three  weeks. 
Rarely  the  hsematuria  is  intermittent,  the  urine  remaining  clear 
for  ten  days  at  a  time. 

The  blood  is  bright  at  first,  but  later  a  large  quantity  of  dark 
disintegrated  blood  may  be  discharged  from  the  rupture  of  a 
collection  of  blood  into  the  kidney  pelvis  {hcematuria  tardive — 
Tuffier  and  Levi). 

Clotting  of  the  blood  in  the  renal  pelvis  may  block  the  ureter 
and  prevent  haematuria.  Clots  may  be  passed  down  the  ureter 
and  give  rise  to  ureteric  colic.  If  there  is  clotting  of  the  blood 
in  the  bladder,  retention  of  urine  may  be  caused  by  blocking  of 
the  urethra  with  clot,  or  the  bladder  may  become  distended  with 
masses  of  clot. 

Secondary  haemorrhage  may  occur  on  the  sixteenth  or  eighteenth 
day,  the  primary  hsematuria  having  ceased  a  few  days  after  the 
injury.  This  is  due  to  suppuration  and  sloughing  of  the  injured 
kidney. 

Changes  in  the  quantity  of  urine. — Oliguria  or  anuria  may 
follow  injury  to  the  kidney,  and  may  be  due  to  injury  affecting 
both  kidneys,  or  to  injury  to  one  kidney  when  the  second  kidney 
is  diseased  or  atrophied.  More  frequently  the  uninjured  kidney  is 
healthy  and  the  suppression  of  urine  is  dae  to  a  depressant  reflex 
exercised  upon  it  by  the  injured  organ. 

Marsius  has  described  fibres  in  the  vagi  and  splanchnic  nerves, 
stimulation  of  which  contracts  the  renal  vessels  and  suspends  the 
secretion  of  urine.  Stimulation  of  either  vagus  stops  the  secretion 
of  both  kidneys. 

The  interference  with  the  renal  function  may  be  temporary, 
lasting  for  twelve  or  twenty-four  hours  after  the  injury,  or  it 
may  persist  and  cause  death.  Polyuria  frequently  follows  upon 
the  oliguria,  appearing  in  twenty-four  or  thirty-six  hours,  or  later 
up  to  the  twelfth  or  fifteenth  day,  and  lasting  for  several  days. 
Polyuria  persisting  beyond  this  time  is  usually  due  to  traumatic 
nephritis.  Discoloration  of  the  skin  in  the  lumbar  region  appears 
four  or  five  days  after  the  injury. 

In  two  or  three  weeks  discoloration  may  be  found  at  the  external 
abdominal  ring,  passing  down  into  the  scrotum  or  labium.  Blood 
may  pass  down  behind  the  peritoneum  into  the  pelvis,  and  on 
rectal  examination  can  sometimes  be  felt  behind  the  bladder. 
Intraperitoneal  effusion  of  blood  may  be  detected  in  the  pouch 
of  Douglas  when  the  peritoneum  has  been  torn. 

Complications  and  sequelae. — Anuria,  retention  of  urine,  and 
pseudo-haematonephrosis  have  already  been  referred  to  in  describ- 
ing the  symptoms. 


VII]  RENAL  INJURIES  101 

Intraperitoneal  haemorrhage. — Intraperitoneal  haemorrhage 
occurs  when  the  peritoneum  is  lacerated,  and  is  most  frequently 
observed  in  children  under  the  age  of  10  years.  It  occurs  in  cases 
of  severe  injury,  and  other  organs — such  as  the  liver  and  spleen 
— are  frequently  injured,  so  that  it  is  impossible  to  say  with 
certainty  that  the  intraperitoneal  haemorrhage  comes  from  the 
kidney.     Such  haemorrhage  is  usually  rapidly  fatal. 

Septic  complications. — When  the  peritoneum  is  lacerated 
there  is  the  further  danger  of  septic  peritonitis  from  infiltration  of 
urine  into  the  peritoneal  cavity. 

It  is  seldom  possible  to  make  a  diagnosis  between  peritonitis 
due  to  rupture  of  the  kidney  and  that  due  to  rupture  of  some 
other  organ,  such  as  the  bowel. 

Infection  of  the  damaged  kidney  is  usually  the  result  of  an 
ascending  infection  from  the  bladder,  and  in  a  large  number  of 
cases  results  from  septic  catheterization.  There  are  cases,  how- 
ever, in  which  no  instrument  has  been  passed  and  infection  of 
the  perirenal  haematoma  must  have  been  due  to  bacteria  carried 
by  the  blood  stream.-  This  has  been  reproduced  experimentally 
by  Albarran. 

The  infection  usually  occurs  soon  after  the  accident,  but  may 
be  delayed  for  some  weeks  or  months.  It  has  been  said  to  occur 
some  years  after  the  injury. 

When  the  perirenal  effusion  of  blood  and  urine  is  infected, 
suppuration  takes  place  and  injured  portions  of  the  kidney  slough, 
so  that  a  large  collection  of  blood,  urine,  pus,  and  disintegrated 
kidney  tissue  is  formed.  Suppuration  may  extend  beneath  the 
diaphragm  and  affect  the  pleura. 

Septic  inflammation  may  be  confined  to  the  kidney  substance 
and  cause  pyelonephritis  or  an  abscess  of  the  parenchyma.  Symp- 
toms usually  develop  soon  after  the  use  of  a  catheter,  and  are 
ushered  in  by  a  rigor.  The  quantity  of  urine  secreted  diminishes, 
and  complete  suppression  may  supervene.  There  is  a  high,  swinging 
temperature  and  an  increase  in  the  local  tenderness  and  swelling. 
The  uninjured  kidney  may  also  be  affected  by  the  ascending  in- 
fection (pyelonephritis)  at  the  same  time  as  the  injured  kidney 
or  at  a  later  date. 

Traumatic  hydronephrosis. — Hydronephrosis  sometimes 
follows  upon  injury  to  the  kidney.  The  number  of  undoubted  cases 
recorded  is  not  great ;  Wildbolz  has  collected  17.  The  obstruction 
may  be  due  to  blocking  of  the  ureter  with  blood  clot,  rupture  of 
or  injury  to  the  ureter,  or  to  pressure  upon  it  of  scar  tissue.  The 
true  hydronephrosis  thus  formed  is  sometimes  indistinguishable 
clinically  from  traumatic  pseudo-hydronephrosis,  in  which  a  cyst 


102  THE   KIDNEY  [chap. 

containing  blood  and  urine  limited  by  adhesions  is  formed  outside 
the  kidney. 

A  swelling  appears  in  the  loin  in  from  two  to  six  weeks  after 
the  injury,  and  may  attain  a  very  large  size.  The  parenchyma  is 
destroyed  in  a  comparatively  short  time.  Hydronephrosis  may 
develop  some  months  or  years  after  an  injury,  and  is  probably  due 
to  undue  mobility  of  the  kidney,  the  result  of  the  injury. 

Movable  kidney. — To  traumatism  is  ascribed  an  important 
role  in  the  causation  of  movable  kidney.  It  has  already  been 
stated  that  94  per  cent,  of  cases  of  laceration  of  the  kidney  are 
in  the  male  sex,  and  the  figures  relating  to  sex  in  movable  kidney 
are  reversed,  namely,  94  per  cent,  female.  From  this  Kiister  has 
inferred  that  "  the  result  of  a  lumbar  injury  in  the  male  is  a 
subcutaneous  contusion  of  the  kidney,  in  the  female  a  movable 
kidney." 

The  number  of  cases  in  which  a  movable  kidney  follows  an 
injury  to  the  loin  cannot,  however,  be  very  great,  for  Tuffier  exam- 
ined a  large  number  of  patients  who  had  previously  suffered  from 
such  an  injury  without  finding  a  single  case  of  movable  kidney. 

Traumatic  nephritis. — Nephritis  is  a  rare  sequela  of  injury 
to  the  kidney.  The  nephritis  is  insidious,  and  usually  takes  the 
form  of  a  chronic  interstitial  nephritis,  with  secondary  vascular 
changes.     Less  frequently  a  parenchymatous  nephritis  develops. 

After  the  haematuria  has  ceased,  albumin  continues  to  be  present 
in  the  urine  and  there  is  continuous  polyuria,  and  epithelial  and 
granular  casts  are  found. 

There  is  sometimes  a  rapidly  appearing  oedema  of  the  feet  and 
face,  or  of  the  entire  body.  The  oedema  is  said  occasionally  to  be 
confined  to  the  side  of  the  body  corresponding  to  the  injury  (Potain). 

In  some  cases  the  symptoms  disappear,  but  in  others  they  per- 
sist, and  in  the  latter  cases  there  may  have  been  chronic  nephritis 
present  before  the  injury. 

It  is  possible  that  an  injury  to  the  kidney  may  rarely  be  the 
cause  of  calculus,  for  a  portion  of  blood  clot  has  been  found 
as  the  nucleus  of  a  renal  calculus.  The  relation  of  trauma  and 
calculus  is,  however,  very  rare. 

Injury  is  said  to  have  been  the  cause  of  cysts  in  the  kidney 
and  of  malignant  growths,  but  in  support  of  this  there  is  no  clear 
evidence. 

Diagnosis. — The  history  of  the  case  and  the  presence  of  bruis- 
ing or  abrasion  in  the  kidney  region  will  point  to  an  injury  of  the 
kidney;  and  if  there  is  renal  and  ureteric  pain,  and  especially  if 
there  is  blood  in  the  urine,  rupture  of  the  kidney  may  be  diagnosed. 
Pain  and  hsematuria  may  be  absent,  from  causes  already  mentioned, 


VII]  RENAL  INJURIES  103 

and  the  diagnosis  must  depend  upon  the  history,  local  swelUng, 
and  rigidity  of  the  abdominal  muscles  on  the  affected  side. 

It  is  impossible  to  judge  accurately  as  to  the  extent  of  the 
injury  from  the  amount  of  blood  or  pain.  A  large,  rapidly  formed 
swelling  in  the  region  of  the  kidney  is  a  sign  of  severe  laceration. 

It  is  necessary  to  inquire  very  carefully  into  the  previous  his- 
tory of  the  patient,  and  to  examine  doubtful  cases  with  the  view 
of  excluding  disease  antecedent  to  the  injury,  such  as  stone, 
growiih,  or  chronic  nephritis. 

Course  and  pro^^nosis. — In  favourable  cases  the  urine  clears 
in  three  or  four  days,  and  the  symptoms  pass  off  and  disappear  in 
a  week  or  ten  days. 

In  severe  cases  the  immediate  dangers  are  shock  and  haemor- 
rhage, and  the  more  remote  septic  complications  and  anuria. 

During  the  period  of  shock  the  appearance  of  a  large  rounded 
swelling  in  the  region  of  the  kidney,  or  of  free  fluid  in  the  peritoneal 
cavity,  denotes  progressive  perirenal  or  intraperitoneal  haemorrhage 
respectively.  When  shock  has  passed  off,  if  there  be  no  signs  of 
progressive  anaemia  and  the  swelling  in  the  loin  be  moderate  and 
show  no  sign  of  increase,  it  may  be  concluded  that  the  haemorrhage 
is  not  immediately  progressive.  Profound  anaemia,  an  increasing 
lumbar  swelling,  and  signs  of  free  intraperitoneal  fluid  denote  con- 
tinued haemorrhage.  The  danger  from  haemorrhage  may  continue 
for  fourteen  or  twenty-one  days  after  the  injury. 

There  is  a  remote  danger  of  recurrent  haematuria  at  intervals 
of  some  months,  and  this  may  continue  for  years  and  eventually 
necessitate  nephrectomy. 

Septic  complications  may  supervene  a  few  days  after  the  injury, 
and  may  follow  catheterization,  or  occur  apart  from  it.  Sepsis  may 
be  delayed  for  some  weeks  or  months,  and  suppuration  has  been 
known  to  occur  in  a  kidney  injured  some  years  previously. 

The  later  the  onset  and  the  less  acute  the  progress  of  the  septic 
process,  the  better  is  the  prognosis.  Prognosis  is  chiefly  affected  by 
haemorrhage  and  injury  to  other  organs.  Recovery  takes  place  in 
70  per  cent,  of  uncomplicated  cases. 

G-rawitz  found  in  108  cases  of  injury  to  the  kidney  that  58 
recovered.  Of  50  cases,  the  fatal  result  was  caused  by  injury  to 
other  vital  organs  in  18,  immediate  haemorrhage  in  14,  delayed 
haemorrhage  in  8,  suppuration  in  7,  and  failure  of  the  renal  func- 
tion in  3. 

The  mortality  is  much  higher  in  children  than  in  adults,  owing 
to  the  greater  frequency  with  which  the  peritoneum  is  ruptured. 

Treatment. — In  cases  of  slight  and  moderately  severe  uncom- 
plicated rupture  of  the  kidney  the  treatment  is  non-operative. 


104  THE   KIDNEY  [chap. 

The  side  is  strapped  with  adhesive  plaster  reaching  to  the  middle 
line  in  front  and  behind  to  prevent  movement,  and  a  broad  bandage 
may  be  applied  over  this  to  give  pressure.  Icebags  should  be  placed 
over  and  under  the  loin,  and  the  patient  kept  absolutely  quiet  in 
the  recumbent  position.  The  food  should  be  fluid.  Hsemostatics 
are  of  little  value,  and  those  which  raise  the  blood  pressure,  such 
as  ergot,  are  harmful.  Calcium  lactate  in  doses  of  10  to  15  gr. 
every  four  hours  may  be  tried ;  it  should  not  be  continued  longer 
than  forty-eight  hours.  Morphia  should  be  given  hypodermically, 
and  serves  the  double  purpose  of  relieving  pain  and  quieting  the 
circulation.  Shock,  if  not  profound,  should  not  be  too  energetic- 
ally treated  lest  bleeding  be  encouraged.  Warmth  to  the  extremi- 
ties and  the  recumbent  position  will  usually  suffice.  If  the  patient 
cannot  pass  water  the  bladder  should  be  emptied  by  catheter  under 
the  most  rigid  aseptic  precautions.  Clots,  if  numerous,  may  be 
washed  out.  If  the  bladder  is  distended,  and  on  passing  a  catheter 
only  a  little  bloody  urine  is  drawn,  there  is  an  accumulation  of  clot 
in  the  bladder,  which  cannot  be  removed  by  catheter.  An  attempt 
may  be  made  by  means  of  a  large  evacuating  cannula  and  bulb, 
such  as  is  used  after  the  operation  of  lithotrity,  to  remove  the  clots 
by  suction,  but  this  method  should  not  be  persisted  in  if  it  be  not 
quickly  successful.  The  bladder  should,  in  case  of  failure,  be 
opened  suprapubically,  the  clots  cleared  out,  and  a  large  rubber 
drainage  tube  introduced.  The  operation  should  be  rapidly  carried 
out.  Should  no  complications  supervene,  the  patient  should  be 
kept  in  bed  for  a  fortnight  after  the  haemorrhage  has  ceased  and 
all  local  tenderness  and  swelhng  have  disappeared. 

Operative  interference  may  be  required  for  the  following 
conditions : — 

1.  Immediate  severe  haemorrhage. 

2.  Delayed  severe  haemorrhage. 

3.  Suppuration  of  the  injured  kidney. 

4.  Septic  peritonitis. 

5.  Hydronephrosis,  pyonephrosis. 

Where  there  is  a  rapidly  increasing  swelling  in  the  region  of  the 
kidney,  or  free  fluid  in  the  peritoneum,  or  severe  persistent  haema- 
turia,  and  especially  where  there  is  progressive  anaemia,  operation 
is  necessary  to  control  the  bleeding.  An  oblique  lumbar  incision 
should  be  made  and  the  damaged  kidney  exposed.  Clots  should 
be  cleared  away  and  a  careful  search  made  for  the  bleeding-point. 
It  may  be  necessary  when  the  haemorrhage  is  free  to  compress  the 
renal  pedicle  with  the  thumb  and  fingers.  A  single  tear  in  the 
kidney  substance  should  be  closed  by  cutgut  sutures  passed  through 
the  substance  of  the  kidney.     If  one  or  several  portions  are  partly 


Mil  RENAL  INJURIES  105 

detached  by  a  number  of  lacerations,  packing  with  strips  of  steril- 
ized gauze  should  be  resorted  to,  and  will  successfully  control  the 
bleeding.  When  a  large  branch  of  the  renal  artery  is  the  source 
of  haemorrhage,  it  should,  if  possible,  be  picked  up  in  long  artery- 
forceps  and  tied  with  a  silk  ligature.  It  may  be  necessary  to 
underrun  the  vessel  with  a  curved  needle  and  silk  in  order  to 
tie  it  securely. 

A  distended  renal  pelvis  should  be  incised  and  the  clots  turned 
out.  If  this  be  followed  by  considerable  haemorrhage,  the  pelvis 
may  be  packed  with  gauze. 

Detached  portions  and  shreds  of  kidney  tissue  should  be  re- 
moved, and  rents  repaired  as  far  as  possible. 

When  the  kidney  is  injured  so  that  repair  does  not  appear 
possible,  primary  nephrectomy  should  be  performed. 

All  operative  measures  should  be  carried  out  with  the  utmost 
dispatch ;  and  when  the  haemorrhage  has  been  controlled,  rectal 
and  intravenous  infusion  of  glucose  solution  (1  per  cent.)  should 
be  given. 

When  there  is  free,  fluid  in  the  peritoneum  and  the  diagnosis 
of  injury  to  the  kidney  is  clearly  established,  the  kidney  should 
first  be  exposed  and  dealt  with,  and  the  peritoneal  cavity  cleared 
of  clots  and  blood  by  an  extension  of  the  lumbar  incision.  When 
the  diagnosis  of  injury  to  the  kidney  is  uncertain,  an  exploratory 
laparotomy  will  be  necessary,  the  abdomen  being  opened  in  the 
middle  hne. 

Nephrectomy  is  called  for  when  there  are  recurrent  attacks 
of  haemorrhage  after  injury  to  the  kidney. 

Suppuration  of  the  damaged  kidney  necessitates  lumbar  ex- 
ploration. Free  incision,  irrigation,  and  drainage  may  be  all  that 
is  necessary,  but  nephrectomy  should  be  performed  if  there  is 
extensive  destruction  of  the  kidney  tissue. 

Laparotomy  and  drainage  of  the  peritoneal  cavity  will  become 
necessary  if  septic  peritonitis  supervene. 

Persistent  anuria  should  be  treated  by  nephrotomy  and  packing. 
The  treatment  of  Hydronephrosis  and  Pyonephrosis  will  be  dis- 
cussed under  those  headings  (pp.  177,  150). 

Results. — The  results  of  operative  treatment  in  injuries  of  the 
kidney  have  greatly  improved  in  recent  years  since  the  necessity 
of  early  aseptic  operation  has  been  recognized. 

Haemorrhage  accounted  for  80  out  of  a  total  190  deaths,  septic 
complications  for  41,  anuria  for  34,  and  shock  for  11  (Watson). 
Of  13  cases  of  nephrectomy  performed  on  account  of  dangerous 
haemorrhage  only  4  died,  and  the  6  patients  most  recently  operated 
upon    all    recovered    (Giiterbock).     W^ilhs    collected    14    cases    of 


106  THE   KIDNEY  [chap. 

nephrectomy  for  injury  to  the  kidney,  with  9  recoveries  and 
5  deaths.  Albarran  collected  6  cases  of  operation  in  which  packing 
of  the  injured  kidney  was  resorted  to,  and  all  recovered. 

The  operative  interference  in  septic  complications  is .  frequently 
postponed  until  too  late,  and  the  already  exhausted  patient  suc- 
cumbs.    Of  7  nephrectomies  of  this  nature,  4  resulted  fatally. 

Nephrotomy  also  has  a  high  mortality.  Of  8  cases,  4  died  after 
the  operation,  and  another  after  a  second  nephrotomy  (Giiterbock). 

The  following  general  statistics  may  be  quoted  with  Riese : 
Of  490  cases  of  uncomplicated  subcutaneous  injuries  to  the  kidney, 
93  (18-9  per  cent.)  died.  There  were  327  treated  by  expectant 
treatment,  and  of  these  69  (21-1  per  cent.)  died,  40  of  the  deaths 
being  due  to  haemorrhage.  In  85  cases  a  conservative  operation 
was  performed  (46  times  on  account  of  bleeding),  and  10  died 
(11-7  per  cent.).  In  78  cases  nephrectomy  was  performed  (54  on 
account  of  bleeding),  and  14  died  (17-9  per  cent.). 

II.    WITH   EXTERNAL  WOUND 

Etiology. — Wounds  of  the  kidney  are  much  less  frequent  than 
subcutaneous  injuries.  They  are  produced  by  stabs  with  a  dagger, 
sword,  bayonet,  hayfork,  etc.,  or  by  bullets. 

Pathology. — The  external  wound  may  lie  in  the  loin,  or  on 
the  anterior  surface  of  the  abdomen,  or  over  the  ribs,  and  accord- 
ing to  the  site  and  direction  of  the  wound  the  intestine,  liver, 
spleen,  or  pleura  may  be  wounded. 

Any  part  of  the  organ  may  be  affected,  and  portions  may  be 
detached  by  bullet  wounds.  With  the  older  forms  of  bullet  the 
ball  and  portions  of  clothing  might  be  embedded  in  the  organ 
and  remain  for  considerable  periods.  A  bullet  may  have  a  burst- 
ing action  on  the  kidney  and  cause  extensive  destruction  of  its 
substance. 

The  blood  escapes  by  the  external  wound,  and,  if  the  calyces 
or  the  pelvis  of  the  kidney  are  wounded,  urine  escapes  along  with 
it.  There  is  no  perirenal  accumulation  of  blood,  except  in  rare 
cases  in  which  the  wound  is  a  long,  sinuous  track.  The  kidney 
may  partly  prolapse  from  a  large  wound. 

The  wound  is  almost  invariably  infected,  so  that  primary 
union  is  very  rare,  and  prolonged  suppuration  common. 

The  organs  which  may  be  wounded  at  the  same  time  as  the 
kidney  are  seen  in  the  diagram  illustrating  the  anterior  relations 
of  the  kidneys  (Fig.  2,  p.  3). 

Urinary  fistulse  occur,  but  seldom  persist.  In  the  American 
Civil  War  there  was  only  one  permanent  fistula  in  74  cases  of 
bullet  wounds  of  the  kidney. 


VII]  RENAL   INJURIES  107 

When  healing  has  taken  place  the  kidney  is  usually  largely 
destroyed,  and  presents  irregular  depressed  scars  and  extensive 
adhesions  to  neighbouring  parts. 

Symptoms. — The  symptoms  differ  in  several  particulars  from 
those  of  subcutaneous  lesions  of  the  kidney.  There  is  no  perirenal 
swelling  of  blood  and  urine.  There  are  external  haemorrhage  and 
escape  of  urine  by  the  wound,  and  occasionally  prolapse  of  the 
kidney. 

The  pain  is  persistent,  but  does  not  radiate  along  the  ureter. 
Haemorrhage  from  stab  wounds  may  be  severe  and  rapidly  fatal. 
In  bullet  wounds  the  external  haemorrhage  is  seldom  severe,  but 
it  may  be  intermittent,  recommencing  after  an  interval  of  about 
five  days. 

The  escape  of  urine  seldom  takes  place  at  first.  It  usually 
occurs  when  the  bleeding  is  diminishing  after  a  few  days.  Occa- 
sionally flatus  from  a  wound  in  the  intestine  is  passed  with  the 
blood  and  urine  from  the  external  wound. 

Septic  complications  occur  on  the  fourth  or  fifth  day  after  the 
injury.  Haemorrhage  has  usually  ceased  at  this  time,  but  it  may 
continue.  With  the  pus,  fragments  of  slough,  portions  of  clothing, 
and  other  materials  are  discharged.  The  track  of  the  wound  may 
become  blocked  by  debris,  and  pus  and  urine  collect  aromid  the 
kidney. 

Diagnosis. — The  diagnosis  is  made  from  the  position  and 
direction  of  the  wound,  the  escape  of  urine,  and  the  occurrence  of 
haematuria. 

Prognosis. — In  wounds  of  the  kidney  the  prognosis  is  com- 
paratively good,  and  operation  is  frequently  undertaken  with 
success.  Wounds  of  other  organs  increase  the  gravity  of  the 
prognosis.  TujSier  found  that  in  31  cases  8  died,  and  in  6  of  these 
the  fatal  result  was  due  to  complicating  injuries. 

The  mortality  of  incised  wounds  of  the  kidney  is  as  low  as 
15  per  cent.  (Albarran),  but  bullet  wounds  have  a  high  mortality 
— namely,  53  per  cent.  (Klister).  The  mortality  of  bullet  and 
other  wounds  of  the  kidney  in  the  American  Civil  War  was  66-2 
per  cent. 

The  statistics  are  all  compiled  from  cases  treated  before  the 
development  of  aseptic  wound  treatment  and  abdominal  surgery. 
The  duration  of  healing  varies  from  three  weeks  to  three  months  ; 
rarely  it  may  be  prolonged  to  two  years.  After  healing  of  the 
womid,  sequelae  such  as  inflammation  in  the  urinary  tract,  fistulae, 
etc.,  may  cause  chronic  invalidism.  Of  52  recently  healed  wounds 
of  the  kidney  Tuffier  found  22  with  sequelae. 

Treatment. — If   the   external   haemorrhage   is   moderate   and 


108  THE   KIDNEY  [chap,  vii 

diminishing,  it  will  suffice  to  clean  and  dress  the  wound.  A  careful 
watch  is  kept  for  recurrent  haemorrhage  and  septic  complications. 
If  there  is  any  reason  to  suspect  that  a  foreign  body  is  lodged  in 
the  wound,  the  track  should  be  freely  opened  up  and  the  kidney 
exposed  and  examined. 

If  the  haemorrhage  is  severe  and  persistent  the  kidney  should 
be  exposed  by  an  oblique  lumbar  incision.  A  single  wound  in  the 
kidney  may  be  closed  with  catgut  sutures.  Detached  portions  of 
the  kidney  may  require  removal,  or,  if  the  kidney  is  extensively 
lacerated,  nephrectomy  may  be  necessary. 

When  a  large  vessel  is  wounded  at  the  hilum  it  may  be  very 
difficult  to  control  the  haemorrhage,  and  clamps  must  be  placed 
upon  the  pedicle.  If  the  blood  supply  of  the  kidney  is  entirely 
cut  off  in  this  way,  it  will  be  necessary  to  remove  the  kidney. 
Kiister  advises  that,  when  a  doubt  exists  as  to  the  blood  supply 
being  sufficient  to  nourish  the  kidney,  the  clamps  be  left  on  for 
a  day  and  then  removed  on  the  operating  table.  If  the  kidney 
now  bleeds  when  it  is  pricked,  it  may  be  left  and  packed  with 
gauze ;  if  it  fails  to  bleed,  nephrectomy  is  performed. 

A  kidney  prolapsed  into  a  large  lumbar  wound  is  cleansed, 
examined,  and  replaced  if  necessary,  being  fixed  in  position  by 
means  of  catgut  stitches.  The  wound  is  then  cleansed  and  partly 
closed,  and  a  large  drainage  tube  inserted. 

In  complicated  cases  in  which  it  is  probable  that  other  organs 
are  wounded  an  exploratory  laparotomy  will  be  necessary 

LITERATURE 

Curschmann,  Munch,  med.  Woch.,  1902,  xlix.  38. 

Belhet,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1901,  xix.  669. 

Keen- Spencer,  ^?iw.  Surg.,  Ang,.,  1896,  xxiv. 

Klippel  et  Chabrol,  Presse  Med.,  1900,  p.  265.  [vol.  ii.,  pt.  ii. 

Medical  and  Surgical  History  of  the  War  of  the  American  Rebellion, 

Riese,  ylrc/t.  /.  Uin.   Chir.,  190.3,  vol.  Ixxi. 

Tuffier,  .4rc;^.  Ge7i.  de  Med.,  1888,  cxxii.  298,  cxxiii.  335. 

Waldvogel,  Devts.  Zeits.  f.  Chir.,  1902,  vol.  Ixiv. 

Watson,  Boston  Med.  Surg.  Journ.,  July  9,  1903,  p.  16. 

Wildbolz,  Zeits.  f.   Urol.,  1910,  iv.  241. 


CHAPTER  VIII 
ANEURYSM  OF  THE  RENAL  ARTERY 

This  is  a  rare  condition.     Only  25  cases  were  found  by  Skillern  in 
the  literature. 

Etiology. — The  condition  is  usually  due  to  traumatism,  but  it 
is  sometimes  spontaneous  (12  traumatic.  7  spontaneous — Morris). 
In  traumatic  cases  the  majority  are  men  in  the  most  active  period 
of  life  ;  in  spontaneous  cases  the  sexes  are  about  equally  divided, 
and  the  majority  are  over  40  years  of  age.  The  form  of  injury 
which  causes  the  aneurysm  is  similar  to  that  which  produces 
rupture  of  the  kidney,  such  as  a  fall  across  a  cart-wheel.  In 
spontaneous  cases  endocarditis  or  arterial  degeneration  is  usually 
present. 

Pathology. — The  aneurysm  is  formed  in  relation  to  the  main 
trunk  of  the  renal  artery  or  one  of  its  large  branches.  It  may 
be  fusiform  or  sacculated,  and  it  may  be  associated  with  a  false 
aneurysm  formed  either  by  rupture  of  a  branch  of  the  renal  artery 
at  another  part  or  by  rupture  of  the  aneurysm  itself. 

The  aneurysm  may  vary  from  the  size  of  a  hazel-nut  to  a  large 
swelling  occupying  the  whole  of  the  loin  and  extending  inwards 
as  far  as  the  middle  line.  A  small  aneurysm  may  press  upon  the 
kidney  and  cause  atrophy  of  the  parenchyma  adjacent  to  it.  When 
the  aneurysm  is  large,  and  especially  when  a  false  aneurysm  has 
been  formed,  the  kidney  tissue  is  extensively  destroyed  by  pressure. 
The  blood  may  track  along  the  renal  vessels  and  accumulate  within 
the  capsule  of  the  kidney,  which  is  greatly  distended.  Rupture 
may  take  place  into  the  renal  pelvis,  which  becomes  distended 
with  blood,  and  the  kidney  is  dilated  to  form  a  hsematonephrosis. 
Rupture  of  the  wall  of  the  sac  and  the  overlying  peritoneum  will 
be  followed  by  escape  of  blood  into  the  peritoneal  cavity. 

When  the  aneurysmal  sac  increases  in  size  it  displaces  the 
colon  forwards  and  inwards,  and  the  liver  or  spleen  upwards. 
Adhesions  are  formed  mth  neighbouring  structures,  which  vary 
in  density  and  thickness.  The  sac  is  lined  by,  and  most  of  its 
cavity  filled  with.,  laminated  clot,  so  that  it  contains  only  a  small 
quantity  of  fluid  blood. 

109 


no  THE   KIDNEY  [chap,  vm 

Symptoms. — Some  of  the  smaller  aneurysms  recorded  have 
been  discovered  post  mortem,  and  have  caused  no  symptoms  during 
life.  With  large  or  with  false  aneurysms  there  is  a  tumour  situated 
in  the  region  of  the  kidney  which  has,  in  most  cases,  followed  upon 
an  injury  to  the  loin.  The  tumour  may  appear  some  days  or  weeks 
after  the  injury,  but  two  years,  or  even  fourteen  years,  may  elapse 
before  a  swelling  is  noticed.  It  is  smooth,  slightly  movable  or 
fixed,  and  does  not  move  with  respiration.  It  is  not  painful  or 
tender,  unless  in  a  few  exceptional  instances.  Hsematuria  is  an 
early  symptom,  and  usually  precedes  the  discovery  of  the  swelling. 
It  may  immediately  follow  the  injury  and  be  continuous,  or  there 
may  be  an  interval  of  months  or  years,  or  the  hsematuria  may  be 
recurrent.  Profuse  and  rapidly  fatal  haemorrhage  may  be  caused 
by  the  rupture  of  an  aneurysm  into  the  renal  pelvis.  Pulsation 
has  rarely  been  observed.  It  was  present  in  one  case,  and  very 
indistinct  in  two  others.  In  Morris's  case  there  was  a  loud  systolic 
bruit,  best  heard  in  front,  over  the  tumour. 

Diagnosis. — The  condition  has  been  diagnosed  once,  and 
suspected  in  two  other  cases.  When  pulsation  is  absent  the  only 
means  of  diagnosis  is  exploratory  operation.  The  conditions  with 
which  aneurysm  of  the  renal  artery  is  most  likely  to  be  confused 
are  ruptured  kidney  with  hsematuria,  and  hsematonephrosis. 

Prognosis. — Albert,  Hahn,  and  Keen  have  each  operated 
successfully  in  one  case.  All  the  other  patients  in  whom  the 
aneurysm  caused  a  tumour  died.  Aneurysms  cause  no  symptoms 
and  are  discovered  accidentally  post  mortem. 

Treatment. — The  condition  will  usually  be  discovered  in  the 
course  of  an  exploratory  operation  undertaken  for  a  swelling  in 
the  loin  which  has  followed  an  injury.  The  sac  should  not  be 
opened  up  more  than  is  sufficienib  to  recognize  the  laminated 
character  of  the  contents. 

In  breaking  down  adhesions  severe  hsemorrhage  has  taken 
place  and  necessitated  plugging  with  gauze.  In  such  a  dilemma, 
and  in  a  case  where  diagnosis  has  previously  been  made,  the 
peritoneal  cavity  should  be  opened  in  the  semilunar  line.  The 
peritoneum  is  divided  along  the  outer  side  of  the  colon  and 
reflected  inwards.  The  pedicle  of  the  kidney  is  exposed  and 
ligatured.     The  aneurysmal  sac  and  kidney  are  then  removed. 

LITERATURE 

Barnard,  Trans.  Path.  Soc,  1901,  lii.  254. 

Hahn,  JDeuts.  med.  Woch.,  1894,  xx.  32. 

Keen,  Philad.  Med.  Journ.,  1900,  p.  1038. 

Morris,  Lancet,  1900,  ii.  1902. 

Skillern,  Journ.  Amer.  Med.  Assoc,  1906,  xlvi.  37. 

Ziegler,  Gentralbl.  f.  Grenzgeb.  d.  Med.  ti.  Chir.,  1903,  vi.  2. 


CHAPTER  IX 
PERINEPHRITIS   AND   PERINEPHRITIC   ABSCESS 

PERINEPHRITIS 

Chronic  perinephritis  leads  to  the  formation  of  a  layer  of  inflam- 
matory tissue  aromid  the  kidney. 

Two  forms  are  observed  :  a  fibrous  or  sclerotic  and  a  fibro- 
lipomatous form.  They  both  result  from  long-continued  inflam- 
mation which  has  not  reached  the  stage  of  suppuration,  and  it 
is  seldom  that  a  purely  fibrous  or  a  purely  lipomatous  form  can  be 
distinguished. 

The  kidney  is  invariably  diseased.     Any  form  of  chronic  in 
flammatory  disease  may  be  present,  such  as  pyelonephritis,  pyo- 
nephrosis, calculus,  tuberculosis. 

The  change  takes  place  in  the  fatty  capsule  of  the  kidney,  and 
in  old-standing  cases  tough  adhesions  are  formed  with  the  sur- 
rounding structures,  especially  the  diaphragm,  liver,  colon,  duo- 
denum, and  peritoneum. 

In  the  sclerotic  form  the  fatty  capsule  of  the  kidney  is  replaced 
by  a  dense  layer  of  fibrous  tissue  which  binds  the  organ  to  the 
surrounding  structures.  The  kidney  is  usually  small  and  shrunken, 
and  may  sometimes  be  difficult  to  find  at  operation.  I  operated 
upon  a  child  of  9  years  with  subacute  pyelonephritis  and  a  renal 
calculus,  and  found  a  mass  of  perinephritic  fibrous  tissue,  |  to  f  in. 
in  thickness,  that  cut  like  cartilage  and  was  fused  with  the  ribs, 
diaphragm,  and  peritoneum.  On  cutting  a  window  through  this 
the  kidney  was  found  and  the  stones  were  removed. 

In  the  more  common  fibro-lipomatous  form  the  delicate  peri- 
renal fat  is  replaced  by  coarse  nodular  fat  with  a  tough  fibrous 
stroma,  the  whole  mass  being  adherent  to  the  neighbouring  struc- 
tures. The  fibrous  capsule  of  the  kidney  is  firmly  adherent  to 
this  fibro-lipomatous  envelope,  but  is  easily  stripped  from  the 
kidney  itself,  so  that  a  subcapsular  nephrectomy  may,  if  required, 
be  quickly  and  easily  performed.  The  mass  is  closely  adherent 
around  the  hilum  to  the  pedicle  of  the  kidney,  and  there  may  be 
difficulty  in  securing  the  vessels  in  such  an  operation. 

Ill 


112  THE   KIDNEY  [chap. 

When  the  pelvis  of  the  kidney  is  the  chief  seat  of  disease  the 
fibro-hpomatous  mass  is  developed  principally  in  this  situation. 
When  one  pole  of  the  kidney  contains  an  abscess,  this  part  only 
may  be  surrounded  by  an  adherent  fibrous  or  fibro-lipomatous 
mass. 

Symptoms.  —  The  symptoms  of  chronic  perinephritis  are 
slight,  and  are  merged  in  those  of  the  underlying  renal  disease. 
Some  part  of  the  aching  and  tenderness  in  the  loin  and  the  local 
rigidity  of  the  abdominal  muscles  in  cases  of  pyelonephritis  and 
pyonephrosis,  etc.,  may  be  referred  to  perirenal  inflammation. 

At  the  same  time  a  tuberculous  kidney  may  become  surrounded 
by  a  thick  layer  of  chronic  inflammatory  tissue  without  ever  having 
given  rise  to  pain  or  discomfort. 

The  volume  of  the  kidney  is  increased  on  palpation,  but  it  is 
impossible  to  say  what  part  of  the  increase  is  perirenal  and  what 
renal.     The  movements  of  the  kidney  are  not  appreciably  limited. 

The  treatment  of  perinephritis  is  that  of  the  renal  disease 
which  has  caused  it. 

PERINEPHRITIC  ABSCESS 

A  perinephritic  abscess  may  occur  at  any  age,  and  may  be 
primary  or  secondary. 

In  230  cases  collected  by  Kiister  the  age  was  from  25  to  40. 
Recently,  Townsend  has  described  cases  of  5  and  15  years,  and 
Gibney  collected  28  cases  of  children  aged  from  1|  to  15  years. 

Men  are  more  frequently  affected  than  w;omen  (140  men  to 
68  women — Kiister),  and  the  right  side  more  often  than  the  left. 
The  abscess  is  very  rarely  bilateral. 

Etiology. — The  primary  form  may  follow  injury  to  the  kidney, 
suppuration  occurring  immediately,  or  sometimes  after  months  or 
years.  More  frequently  it  develops  during  the  course  of  some 
fever  such  as  typhoid,  scarlatina,  measles,  or  pneumonia  ;  or  it 
may  appear  when  the  patient  is  suffering  from  tonsillitis,  car- 
buncle, boils,  or  even  eczema. 

The  secondary  form  complicates  suppuration  in  some  neigh- 
bouring organ,  such  as  the  kidney  (about  25  per  cent.),  liver,  gall- 
bladder, appendix,  pelvic  organs,  or  vertebrae,  or  duodenal  ulcer. 

Tuberculous  perinephritic  abscess  is  very  rarely  secondary  to 
tuberculosis  of  the  kidney.  It  is  especially  found  in  tuberculous 
disease  of  the  vertebrae. 

Pus  from  an  empyema  or  an  abscess  of  the  lung  may  track 
through  the  costo-lumbar  hiatus  of  the  diaphragm  and  form  a 
perinephritic  abscess. 

Bacteriology. — The   following   bacteria    are   found,    and    are 


IX]  PERINEPHRITIC  ABSCESS  113 

given  in  their  order  of  frequency,  viz.  bacterium  coli  commune, 
streptococcus,  staphylococcus.  The  gonococcus  and  pneumo- 
coccus  are  rare. 

Pathology. — The  abscess  is  usually  unilocular,  but  occasion- 
ally there  are  multiple  abscesses.  It  is  situated  outside  the  fibrous 
capsule,  and  may  lie  inside  or  outside  the  perinephritic  fascia. 
In  the  former  case  the  pus  will  tend  to  spread  down  the  ureter  into 
the  bony  pelvis,  while  in  the  latter  it  will  appear  on  the  surface 
of  the  body  over  the  iliac  crest,  or  pass  into  the  iliac  fossa. 

There  is  a  tendency  to  the  formation  of  fibrous  tissue  in  the 
early  stages  of  the  suppuration,  so  that  the  pus  becomes  shut  in 
and  tends  rather  to  rupture  in  one  direction  than  to  spread  widely 
in  the  retroperitoneal  tissue. 

Four  varieties  are  distinguished  according  to  situation  : — 

1.  Above  the  kidney,  or  subphrenic,  which  is  frequently  con- 
nected A\T.th  intrathoracic  suppuration.  The  kidney  is  pushed 
downwards,  and  may  be  felt  below  the  subphrenic  mass. 

2.  Below  the  kidney,  which  tends  to  pass  downwards  to  the 
iUac  fossa,  and  may  rupture  into  and  pass  .along  the  psoas  sheath 
and  appear  in  Scarpa's  triangle,  or  may  pass  into  the  pelvis  and 
escape  at  the  sciatic  notch. 

3.  In  front  of  the  kidney,  hmited  by  peritoneum.  This  form 
is  very  rare ;  it  may  rupture  into  the  peritoneal  cavity,  bowel, 
bladder,  or  vagina. 

4.  Behind  the  kidney — a  much  more  common  variety,  which 
may  pass  through  the  muscles  of  the  loin  at  the  triangle  of  Petit. 

Symptoms. — When  the  perinephritic  abscess  compUcates  some 
other  disease  the  symptoms  are  superadded  to  those  of  the  primary 
disease. 

When  the  perinephritic  suppuration  is  primary  the  onset  is 
usually  insidious  and  the  pain  slight  and  insignificant.  The  general 
condition  of  the  patient  is  bad,  and  there  is  fever  of  the  high 
remittent  type.  The  temperature  rises  to  102°  or  103°  F.  at  night, 
and  falls  to  normal  or  a  little  above  it  in  the  morning.  In  rare 
cases  the  temperature  is  not  raised.  Occasionally  the  onset  is 
sudden  and  is  heralded  by  a  rigor.  It  is  often  difiicult  to  find  the 
cause  of  the  illness  at  this  stage. 

Pain  and  tenderness  over  the  kidney  become  marked.  The 
pain  may  radiate  to  the  shoulder  or  arm,  but  more  frequently  it 
passes  downwards  to  the  scrotum  or  labium.  It  is  increased  by 
movement  and  by  respiration,  coughing  and  sneezing. 

There  is  increasing  tenderness  on  palpation  of  the  loin,  and 
the  abdominal  muscles  of  that  side  are  rigid,  so  that  examination 
is  difficult  without  an  ansesthetic. 


114  THE   KIDNEY  [chap. 

The  patient  complains  of  stiffness  of  the  corresponding  thigh, 
which  becomes  flexed  and  rotated  sHghtly  outwards.  There  is 
restricted  extension,  but  no  hmitation  of  flexion.  The  position  is 
that  of  contraction  of  the  psoas.  There  may  be  transient  paralysis 
of  the  lower  limb. 

A  characteristic  tumour  forms  in  the  loin.  The  waist  line  is 
obliterated,  and  the  whole  loin  bulges  outwards  and  backwards. 
The  anterior  swelling  is  less  than  appears  in  cases  of  enlarged 
kidney.  The  tumour  does  not  move  with  respiration.  It  may 
be  moved  a  little  between  the  hands,  but  it  does  not  give  the 
sensation  of  ballottement. 

There  may  be  oedema  of  the  overlying  skin.  Very  rarely  fluc- 
tuation can  be  detected.  Some  variation  in  symptoms  may  be 
observed  according  to  whether  the  abscess  is  situated  mainly  above 
or  mainly  below  the  kidney. 

In  the  variety  above  the  kidney,  in  addition  to  the  symptoms  of 
involvement  of  the  pleura  and  lung  there  may  be  jaundice,  ascites, 
and  oedema  of  the  legs,  and  persistent  vomiting  when  the  right 
side  is  affected.  These  symptoms  are  caused  by  the  relation  of 
the  abscess  to  the  gall-bladder,  inferior  vena  cava,  and  duodenum. 

An  abscess  below  the  kidney  is  characterized  by  constipation 
from  the  colon  being  affected,  symptoms  of  involvement  of  the 
psoas  muscle  {see  above),  neuralgic  pain  referred  to  the  groin  and 
genital  organs,  and  retraction  of  the  testicle.  The  swelhng  invades 
the  ihac  fossa  and  may  pass  under  Poupart's  hgament. 

Pyuria  will  be  present  in  the  cases  where  the  kidney  is  the 
cause  of  the  perinephritic  abscess,  unless  the  ureter  is  blocked. 
In  acute  cases  pus  forms  in  ten  or  twelve  days,  while  in  less  acute 
cases  pus  may  not  be  detected  for  three  or  four  weeks.  In  tuber- 
culous cases  the  abscess  is  usually  secondary  to  disease  in  the 
vertebra,  acute  symptoms  are  absent,  and  pain  and  tenderness 
are  slight. 

If  no  operation  is  performed  the  patient  either  dies  of  septicaemia 
or  the  abscess  ruptures  into  some  neighbouring  organ  or  on  the 
surface  through  the  muscular  triangle  of  Petit.  Kiister  gives  the 
following  statistics  of  rupture  :  Pleura  and  bronchi,  .  18  cases ; 
intestine  (colon),  11  cases;  peritoneum,  2  cases;  bladder,  or  bladder 
and  vagina,  3  cases. 

Diagfnosis. — The  condition  has  been  mistaken  for  typhoid 
fever  or  malaria  in  the  early  stage,  and  disease  of  the  hip-joint  or 
pyonephrosis  at  a  later  period. 

When  only  fever  and  general  symptoms  are  present,  leuco- 
cytosis  suggests  that  suppuration  is  taking  place  in  the  body ;  a 
negative  Widal   reaction  will    exclude   typhoid  fever,  and   exam- 


IX]  PERINEPHRITIG  ABSCESS  115 

ination  of  the  blood  will  eliminate  malaria.  Against  hip-joint 
disease  there  is  the  freedom  of  flexion  and  rotation  of  the  thigh, 
and   the  absence  of  local   tenderness. 

A  pyonephrosis  is  regular  and  well  defined.  It  moves  with 
respiration,  projects  forwards  rather  than  laterally  or  backwards, 
and  does  not  cause  oedema  of  the  skin.  A  pyonephrosis  may  be 
present  and  concealed  by  a  perinephritic  abscess. 

Prognosis. — Spontaneous  cure  is  very  rare  and  cannot  be 
hoped  for.  Good  results  are  obtained  by  prompt  operation  in 
primary  cases.  The  longer  the  operation  is  delayed  the  worse  is 
the  prognosis.  The  prognosis  in  secondary  perinephritic  abscess 
depends  upon  the  original  cause.  Kiister  collected  230  cases  at  a 
period  when  the  importance  of  early  operation  was  imperfectly 
understood,  and  found  151  (65-6  per  cent.)  recovered.  Fistulse 
persisted  in  6  of  these  cases. 

Treatment. — Early  operation  is  the  only  successful  method 
of  treatment.  The  kidney  is  exposed  by  an  oblique  incision,  and 
the  abscess  drained.  The  lumbar  muscles  are  found  oedematous, 
and  the  abscess  lies  immediately  under  the  lumbar  fascia.  The 
cavity  should  be  explored  in  all  directions,  so  that  no  pockets  are 
left  undrained.  Subphrenic  collections  of  pus  and  those  in  the 
iliac  fossa  are  searched  for  and  opened  up. 

Counter-openings  may  be  necessary  in  the  loin  or  elsewhere  to 
ensure  free  drainage. 

If  the  kidney  is  the  seat  of  abscess,  pyelonephritis,  or  pyo- 
nephrosis, it  should  be  freely  incised  and  drained.  If  nephrectomy 
be  necessary  it  should  be  postponed  to  a  later  date. 

When  the  abscess  has  originated  in  an  empyema,  this  should 
also  be  drained. 

In  old-standing  cases,  when  sinuses  have  persisted,  a  diseased 
kidney  or  an  imperfectly  drained  empyema  may  necessitate  nephrec- 
tomy, resection  of  portions  of  ribs,  or  other  secondary  operations. 

Watson  compared  two  series  of  cases  where  perinephritic  sup- 
puration had  followed  injuries  to  the  kidney.  Of  21  cases  treated 
without  operation  17  died  (80  per  cent.),  while  in  28  cases  treated 
by  operation  2  died  (7*1  per  cent.). 

LITERATURE 

Albarran,  Soc  de  Biol.,  1889. 

Guiteras,  New  York  Med.  Journ.,  1906,  Ixxxiii.  169. 

Kiister,  Chirurgie  der  Nieren.     1902. 

Maas,  Volkmanns  Sammlung  klin.  Vort,  1897,  p.  605.  ' 

Townsend,  Journ.   Amer.  Med.   Assoc,  1904,  xUii.  1626. 

Watson,  Boston  Med.  Surg.  Journ.,  190.3,  cxlix.  29,  64. 

Zuckerkandl,  Wien.  klin.  Woch.,  Oct.  13,  1910. 


CHAPTER   X 

SURGICAL  INFLAMMATION  OF  THE  KIDNEY 
AND  PELVIS 

Classification  and  nomenclature. — The  inflammations  of  the 
kidney  and  pelvis  met  with  in  surgical  practice  may  be  either 
non-bacterial  or  bacterial.  The  non-bacterial  inflammations  are 
caused  by  the  excretion  of  irritants  or  by  mechanical  means. 
The  bacterial  diseases  are  divided  for  convenience  into  those  pro- 
duced by  the  ordinary  pathogenic  bacteria  and  those  due  to  the 
tubercle  bacillus,  the  fungus  of  actinomycosis,  and  the  spirochsete 
of  syphilis. 

When  the  kidney  is  affected  alone  the  term  "  nephritis  "  is  used, 
and  when  the  kidney  substance  contains  scattered  abscesses  the 
condition  is  named  "  suppurative  nephritis."  When  a  single  abscess 
or  several  large  abscesses  are  present,  then  the  disease  is  termed 
"  abscess  of  the  kidney."  When  the  kidney  and  pelvis  are  affected 
"  pyelonephritis  "  is  present,  and  when  the  pelvis  alone  is  inflamed 
"  pyelitis  "  exists.  If  obstruction  to  the  outflow  of  urine  compli- 
cates pyelitis  or  pyelonephritis  the  kidney  becomes  distended  with 
pus  and  urine,  and  a  "  pyonephrosis  "  is  formed. 

Bacteriology  of  renal  infections. — The  bacillus  coU  communis 
is  the  most  common  cause  of  renal  infection,  occurring  in  75  per 
cent,  of  cases.  The  next  most  frequent  are  the  staphylococcus 
(especially  the  aureus),  the  streptococcus,  the  proteus  of  Hauser, 
and  the  bacillus  pyocyaneus.  The  pneumococcus  and  gonococcus 
are  rare.  The  bacillus  coli  is  usually  found  in  pure  culture,  but 
occasionally  in  a  mixed  infection  with  the  proteus,  staphylococcus, 
or  streptococcus.  Anaerobic  bacteria  are  occasionally  found, 
especially  in  pyonephrosis. 

The  staphylococcus  and  proteus  vulgaris  cause  decomposition 
of  urea,  and  the  urine  rapidly  becomes  ammoniacal.  In  the  rare 
pure  streptococcal  infections  and  the  common  bacillus  coli  infec- 
tions the  urine  remains  acid.  Where  the  urine  of  the  infected 
kidney  is  alkaline  the  blended  urine  of  two  kidneys  may  be  acid. 

116 


CHAP.  X]  SURGICAL   INFLAMMATION  117 

ASEPTIC   PYELONEPHRITIS 

L  Due  to  Acute  Retention  op  Urine 
Guyon  and  Albarran  have  described  a  form  of  pyelonephritis 
observed  experimentally  in  acute  retention  of  urine.  There  is 
acute  congestion  of  both  kidneys,  which  may  go  on  to  interstitial 
and  intratubular  haemorrhages  with  desquamation  of  the  epithelium 
of  the  tubules.  Clinically  there  is  lessened  secretion  of  urine.  The 
urine  contains  a  reduced  quantity  of  salts,  and  blood,  renal  cells, 
blood  casts  and  epithelial  casts  are  present. 

When  the  retention  is  relieved  there  is  polyuria,  and  the  urine 
contains  casts  for  some  days.  If  the  obstruction  is  completely 
relieved  and  no  sepsis  is  present,  the  symptoms  entirely  disappear. 

2.  Due  to  the  Excretion  of  Irritants 

A  mild  catarrhal  pyelonephritis  may  be  set  up  by  the  elimina- 
tion of  certain  balsamics  such  as  sandal-wood,  copaiba,  turpentine, 
etc.  There  is  pain  in  the  renal  region  and  often  increased  fre- 
quency of  micturition;  The  urine  contains  a  little  albumin,  and 
cells  derived  from  the  renal  pelvis.  The  symptoms  disappear  when 
the  drug  is  withheld. 

The  excretion  of  cantharides  produces  nephritis,  at  first  catar- 
rhal, then  interstitial ;  there  are  also  catarrhal  pyelitis  and  cystitis. 
The  urine  is  scanty,  high-coloured,  and  contains  blood,  albumin, 
mucus,  and  fibrin.  Microscopically,  the  urine  contains  cells  from 
the  urinary  tract,  and  also  hyaline  and  epithelial  casts.  The 
oliguria  may  become  anuria.  The  condition  may  subside  when 
the  elimination  of  cantharides  ceases  and  the  patient  is  placed 
upon  a  milk  diet ;  but  it  may  pass  into  chronic  interstitial  nephritis. 

3.  In  Chronic  Urinary  Obstruction 

In  long-standing  obstruction  to  the  outflow  of  urine,  such  as 
stricture,  enlarged  prostate,  or  the  pressure  of  malignant-  pelvic 
growths,  the  ureters  become  dilated  and  thickened  and  lose  their 
contractile  power,  and  the  pelvis  of  the  kidney  is  dilated.  The 
apices  of  the  pyramids  become  flattened,  the  sinus  of  the  kidney 
is  hollowed  and  more  spacious,  and  the  calyces  are  dilated.  The 
lining  membrane  of  the  pelvis  becomes  opaque  and  tough  and 
loses  its  brilliancy.  The  kidney  is  enlarged,  and  when  not  dis- 
tended with  fluid  is  flabby. 

The  kidney  substance  is  narrower,  both  cortex  and  medulla 
being  reduced  in  width.  The  differentiation  between  the  layers 
remains  distinct,  but  the  fine  structure  is  lost.  The  substance  is 
tough  and  leathery.     Microscopically  there  is  chronic  interstitial 


118 


THE  KIDNEY 


[chap. 


nephritis  in  an  advanced  degree.  The  interstitial  connective  tissue 
is  increased,  is  moderately  cellular,  and  the  tubules  and  glomeruli 
are  widely  separated.  The  tubules  become  distorted  and  broken 
up,  the  glomeruh  fibrous  and  their  vessels  occluded.     (Fig.  26.) 

Both  kidneys  are  affected,  but  usually  to  an  unequal  degree. 

Symptoms. — Those  of  renal  disease  are  generally  slight,  and 
may  easily  be  overlooked. 

There  is  dull  aching  pain  in  the  posterior  renal  area  on  both 


Fig.  26. — Chronic  interstitial  nephritis  due  to  obstruction 
from  enlarged  prostate. 

sides,  rarely  on  one  side  only  (25-3  per  cent.),  with  constant  thirst, 
sometimes  more  marked  at  night  (26-7  per  cent.).  The  tongue  is 
dry  (12-9  per  cent.),  at  first  along  the  centre,  and  later  over  its 
whole  surface.  Loss  of  appetite  is  present  in  5  per  cent.,  and 
frontal  headache  in  22  per  cent.  There  may  be  appreciable  loss 
of  weight.  The  temperature  is  shghtly  subnormal.  There  are  no 
cardiac  or  vascular  changes.  The  kidneys  cannot  be  felt  on  pal- 
pation, and  are  not  tender.  Polyuria  is  a  constant  symptom. 
The  urine  is  pale  and  clear.  The  percentage  of  urea  and  other 
urinary  constituents  is  much  reduced,  and  the  specific  gravity  is 


X]  PYELONEPHRITIS  119 

low  (1005  to  1010).  The  total  quantities  of  these  bodies  passed 
in  twenty-four  hours  may  be  only  slightly  below  the  normal  standard, 
or  may  be  much  reduced.  The  polyuria  amounts  to  80-100  oz. 
in  twenty-four  hours  ;  it  is  often  more  marked  at  night.  No  tube 
casts  or  other  cellular  elements  are  found  in  the  urine. 

Treatment. — Operation  in  advanced  cases  is  fraught  with 
extreme  danger.  Suppression  of  urine  may  immediately  follow  the 
operation  ;  more  frequently  there  is  gradual  failure  of  the  renal 
function,  with  thirst  and  drowsiness  alternating  with  sleeplessness 
and  restlessness,  gradual  loss  of  flesh,  and  mild  delirium  at  night ; 
and  the  patient  dies  of  syncope  after  gradually  increasing  cardiac 
failure,  a  few  days  or  some  weeks  after  the  operation. 

Chronic  aseptic  pyelonephritis  may  also  be  caused  by  calculus 
and  by  new  growths  of  the  kidney.  If  the  obstruction  to  the 
outflow  of  urine  is  complete  and  intermittent,  the  kidney  becomes 
distended  with  urine  and  a  hydronephrosis  forms  (p.  164).  In 
calculus  of  the  ureter  a  very  pronounced  polyuria  may  be  present, 
which  disappears  when  the  calculus  is  removed,  and  is  apparently 
due  to  reflex  influences  on  the  kidney  of  the  affected  side  {see 
Chart,  p.  327). 

INFECTIVE    PYELONEPHRITIS 

There  are  two  forms  of  pyelonephritis,  which  differ  according 
to  whether  the  infection  occurs  without  previous  disease  of  the 
urinary  tract,  or  is  secondary  to  some  pre-existing  urinary  disease. 
The  first  form,  primary  pyelonephritis,  is  believed  to  be  caused  by 
blood-borne  bacteria,  and  is  therefore  termed  "  haematogenous  "  ; 
while  the  second  form  is  secondary  to  infection  of  the  lower 
urinary  tract,  and  is  termed  "  ascending "  pyelonephritis.  These 
two  forms  will  be  described  separately. 

1.  Primary  or  Hematogenous  Pyelonephritis 

Haematogenous  pyelonephritis  is  a  less  common  form  than 
ascending  pyelonephritis,  but  it  has  been  shown  within  recent 
years  to  occur  with  greater  frequency  than  was  at  one  time  sup- 
posed. The  disease  is  met  with  in  infants,  children,  and  adults. 
In  infants  and  young  children  it  occurs  with  comparative  frequency. 
At  this  age  the  pelvis  is  more  severely  affected  than  the  kidney, 
and  the  condition  will  be  more  conveniently  described  under  the 
heading  of  Pyelitis  of  Infancy  and  Childhood  (p.  141).  Adults  are 
most  frequently  affected  in  the  most  active  period  of  life.  The 
disease  also  occurs  in  pregnant  women,  and  presents  special  fea- 
tures, which  will  be  described  under  the  heading  of  Pyelitis  of 
Pregnancy  (p.   142). 


120  THE   KIDNEY  [chap. 

Of  my  personal  cases  56  per  cent,  were  female  and  44  per  cent, 
male ;  while  the  right  kidney  was  affected  in  50  per  cent.,  the  left 
in  42  per  cent.,  and  both  in  6  per  cent.  Legueu  found  the  right 
kidney  affected  in  93  per  cent,  of  cases. 

Etiology. — The  large  intestine  is  the  chief  source  of  bacteria. 
A  history  of  chronic  constipation  can  be  obtained  in  a  number 
of  cases,  and  occasionally  an  attack  of  diarrhoea  has  preceded  the 
onset  of  renal  symptoms.  Tonsillitis,  boils,  and  carbuncle  are 
sometimes  the  primary  foci.  The  renal  infection  may  occasion- 
ally complicate  influenza  and  typhoid  fever. 

It  is  now  recognized  that  bacteria  are  constantly  entering  the 
lymphatics  from  the  intestine  and  other  sources  in  healthy  in- 
dividuals. The  bacteria  may  be  destroyed  at  the  point  of  entry 
or  at  the  lymphatic  glands,  or  they  may  pass  through  the  lymphatic 
system  into  the  blood  stream,  in  which  they  circulate.  The  endo- 
thelium and  cells  of  the  liver  destroy  bacteria  which  are  introduced 
by  way  of  the  portal  system,  and  bacteria  are  excreted  in  the  bile. 
Similarly  a  function  of  the  renal  parenchyma,  especially  of  the  con- 
voluted tubules,  is  to  remove  the  bacteria  present  in  the  systemic 
circulation. 

It  has  been  proved  that  the  virulence  of  these  bacteria  is  not 
reduced  in  their  passage  through  the  body.  The  excretion  of 
bacteria  in  this  way  does  not  give  rise  to  any  symptoms  which 
show  that  the  kidneys  are  damaged.  It  is  stated,  however,  as 
the  result  of  experiments  on  animals,  that  the  secreting  membrane 
is  injured  by  the  passage  of  the  bacteria.  The  damage  is  probably 
slight,  and  is  repaired  partly  or  completely  by  the  regenerative 
powers  of  the  kidney.  In  some  cases  long-continued  excretion  of 
bacteria  or  their  toxins  may  be  the  cause  of  patches  of  interstitial 
nephritis  in  the  kidney. 

It  is  held  that  the  excretion  of  bacteria  does  not  cause  pyelo- 
nephritis unless  some  additional  factor  is  present.  Predisposing 
causes  of  pyelonephritis  are  traumatism,  excessive  functional 
activity,  the  elimination  of  toxic  bodies  such  as  cantharides,  pre- 
vious disease  of  the  kidney  such  as  urinary  obstruction,  calculus, 
new  growth.  It  is  exceptional,  however,  to  find  any  of  these  factors 
present,  and  it  is  more  likely  that  chronic  toxsemia  from  consti- 
pation, an  excessive  dose  and  an  exceptionally  virulent  strain  of 
bacteria,  are  the  decisive  factors. 

Pathologfy.  i.  Hyperacute  or  fulminating  pyelonephritis. 
— The  kidney  is  large,  plum-coloured,  and  engorged  with  blood. 
The  vessels  at  the  base  of  the  pyramids  are  distended  with  blood. 
The  cortex  is  dark,  the  pyramids  are  paler.  Microscopically,  the 
large  vessels  and  a  few  glomeruli  are  engorged  with  blood,  and  a 


X]         Hy^MATOGENOUS   PYELONEPHRITIS       121 

few  of  the  pyramids  show  dilated  vessels.  The  glomeruli  and 
tubules  are  healthy  in  appearance,  and  the  nuclei  of  the  renal 
epithelial  cells  may  be  well  stained.  (Fig.  27.)  There  may  be  a 
few  ecchymoses,  and  sometimes  a  slight  degree  of  cloudy  swelling 
of  the  epithelium. 

ii.  Acute   pyelonephritis. — The    organ   is    enlarged  and   con- 


Fig.  27. — Microscopical  section  of  kidney  in  postoperative 
suppression  of  urine. 

There  is  engorgement  of  blood-vessels.     The  nuclei  of  the  renal  epithelium  are  well  stained. 

gested.  Scattered  over  the  surface  are  bosses  varying  in  size  from 
a  millet-seed  to  a  large  pea.  On  section  the  cortex  shows  con- 
gestion, and  dots  and  patches  of  greyish  yellow,  some  of  which 
are  wedge-like  in  shape  and  correspond  to  the  bosses  on  the  surface 
of  the  organ.  Ecchymoses  are  frequently  observed.  The  epithe- 
lium of  the  convoluted  tubules  shows  cloudy  swelhng  and  some- 
times desquamation,  and  there  is  proliferation  of  the  endothelium 
of  the  glomeruli.     The  greyish  patches  and  wedges  are  densely 


122  THE   KIDNEY  [chap. 

infiltrated  areas,  where  the  tubules  and  glomeruli  are  obscured  by 
round  cells.  Here  and  there  the  centre  of  these  may  have  broken 
down  so  as  to  form  a  tiny  abscess.  The  infiltration  may  surround 
a  glomerulus  or  a  small  blood-vessel.  The  pelvis  shows  prolifera- 
tion and  desquamation  of  the  epithelium  with  ecchymoses. 

iii.  Subacute  and  chronic. — The  kidney  is  small,  very  tough, 
and  densely  adherent  to  the  sclerosed  perirenal  tissue.  The  sur- 
face is  irregular  and  the  capsule  adherent.  The  substance  of  the 
organ  is  tough  and  fibrous,  the  cortex  and  medulla  are  poorly 
defined.  The  colour  is  either  uniformly  greyish,  or  is  pale  red 
with  grey  areas.  Sometimes  there  are  small  cysts,  which  may  be 
filled  with  pus.  Microscopically  there  is  advanced  chronic  inter- 
stitial nephritis  with  sclerosis  of  glomeruli  and  destruction  of  tubules, 
and  the  fibrous  tissue  is  infiltrated  with  densely  packed  round  cells, 
either  uniformly  distributed  or  in  patches.  The  pelvis  shows  thick- 
ening of  the  mucous  membrane  and  great  proliferation  of  epithe- 
lium.    There  may  be  phosphatic  debris  or  calculi  in  the  pelvis. 

Symptoms.  Prodromal  symptoms. — The  patient  frequently 
has  headache,  lassitude,  and  want  of  appetite  for  a  few  days 
before  the  onset  of  the  acute  symptoms.  Habitual  constipation 
may  have  become  more  pronounced,  or  there  may  have  been  an 
attack  of  diarrhoea. 

In  6-25  per  cent,  of  cases  (5  out  of  80 — Lenhartz)  there  is  a 
sudden  desire  to  pass  water,  followed  by  great  frequency  of  mic- 
turition and  even  strangury.  These  symptoms  may  last  for  an 
hour  or  two,  or  for  one  or  two  days. 

There  are  several  degrees  of  severity  of  the  symptoms  : — 

(a)  Mild  attack. — After  a  rigor  the  temperature  rises  to  101° 
or  102°  F.  The  vesical  irritation  continues,  and  there  is  usually 
aching  across  the  loins,  sometimes  more  marked  on  one  side.  Theire 
is  tenderness  over  one  kidney,  but  the  organ  is  not  enlarged.  The 
urine  is  usually  abundant  and  pale,  with  a  low  specific  gravity  and 
a  stale-fish  odour.  It  is  hazy,  and  on  swinging  the  glass  a  drift- 
cloud  appearance  or  shimmering,  is  seen,  which  is  characteristic  of 
bacilluria.     The  bacillus  coli  communis  is  present  in  pure  culture. 

In  a  few  days  the  temperature  begins  to  subside,  and  in  ten 
or  fourteen  days  it  is  normal.  The  tenderness  of  the  kidney  dis- 
appears. The  urine  may  clear  and  become  sterile,  or  it  may 
remain  hazy  with  bacteria.  In  rare  cases  haematuria  is  an  early 
symptom,  and  persists  for  many  weeks  after  all  other  symptoms 
have  subsided. 

(6)  Acute  attack. — The  initial  rigor  is  severe  and  the  tempera- 
ture rises  to  102°  or  103°  F.  The  patient  is  prostrate,  often  drowsy, 
and  may  be  delirious.     There  is  at  first  general  abdominal  pain  or 


X]         Ht^MATOGENOUS   pyelonephritis        123 


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backache,  and  then  heavy 
aching  pain  in  one  loin ; 
occasionally  attacks  of  se- 
vere renal  colic.  The  ab- 
dominal muscles  are  rigid, 
especially  on  one  side.  There 
is  intense- tenderness  in  the 
region  of  the  kidney  in  front, 
and  at  the  angle  of  the  last 
rib  and  the  erector  spinse 
muscles  behind.  The  kidney  SI 
can  usually  be  felt  enlarged,  | 
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The  second  kidney  is  not 
painful  or  tender. 

The  urine  is  scanty,  acid, 
very  rarely  alkaline  in  reac- 
tion, and  contains  bacteria, 
pus    cells,  and    red    blood- 
corpuscles.      According    to 
Dudgeon    the    bacteria    lie 
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ingly in  urine.     This  is  not, 
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dence  of  active  phagocyto-   § 
sis  in  all  forms  of  bacteria.    ^ 
There  are  hyaline,  granular, 
and    blood   casts,  and    epi- 
thelia   from   the   renal   pelvis    and   bladder  may  be  found.     The 
blood  in  the  urine  is  usually  small  in  quantity. 

When  the  urine  of  each  kidney  has  been  examined  separately, 
that  from  the  diseased  kidney  has  shown  the  characters  just 
described,  while  that  from  the  second  kidney  has  been  normal  or 
has  shown  polyuria.  After  the"  first  few  days  the  bladder  symp- 
toms pass  off.  On  examination  of  the  blood  there  is  a  leucocyte 
count  of  18,000  to  20,000.  The  bacillus  coh  has  been  found  in 
the  blood,  especially  in  young  children. 

The  temperature  may  fall  slightly  and  then  the  rigor  is  repeated, 
the  temperature  shooting  up  to  105°,  106°,  or  even  107°  F.  (Chart 
13),  and  falling  to  normal  or  slightly  above  it.     After  two  or  three 


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124  THE   KIDNEY  [chap. 

weeks  the  acute  symptoms  may  subside  ;  the  temperature  falls> 
gradually  or  quickly. 

When  the  patient  is  allowed  to  get  up  the  symptoms  may  all 
reappear.  The  recurrent  attack  is  due  either  to  infection  of  the 
second  kidney  or  to  recrudescence  of  the  disease  in  the  organ  first 
attacked.  After  the  second  attack  has  subsided,  convalescence 
may  be  established,  but  sometimes  recurrent  attacks  are  brought 
on  each  time  the  patient  gets  up,  for  several  months. 

Instead  of  taking  a  benign  course  after  a  fortnight  or  so,  the 
rigors  may  be  frequently  repeated,  the  temperature  rising  to  105°  or 
107°  F.  after  each,  falling  occasionally  to  normal,  but  usually  keep- 
ing above  100°  F.  There  is  often  a  lull,  during  which  the  patient 
appears  to  improve,  and  then  another  series  of  rigors  follows. 
The  kidney  remains  large  and  tender,  and  the  urine  scanty  and 
bacterial.  The  tongue  becomes  dry  and  brown,  the  appetite  is. 
lost,  and  the  patient  rapidly  emaciates.  Hiccough  appears  occa- 
sionally, and,  then  grows  more  persistent  and  distressing.  The- 
mind  becomes  dull  and  clouded,  and  the  patient  gradually  sinks, 
and  dies  in  from  three  to  six  weeks  after  the  onset    of  the  illness. 

(c)  Fulminating  attack. — The  patient,  previously  in  good 
health,  is  seized  with  a  severe  rigor,  and  the  temperature  mounts 
to  104°  or  105°  F.  He  becomes  heavy,  drowsy,  or  even  comatose. 
Vomiting  occurs,  and  there  is  abdominal  pain  and  sometimes, 
backache,  and  the  abdomen  is  rigid.  The  urine  is  scanty  and  con- 
tains bacteria,  casts,  epithelia,  and  sometimes  blood.  There  may 
be  complete  suppression  of  urine. 

The  patient  may  die  comatose  without  developing  any  symp- 
toms which  point  to  the  kidney,  except  the  condition  of  the  urine. 

Clironic  pyelonephritis  (hsematogenous). — When  the  acute 
stage  of  pyelonephritis  has  subsided,  chronic  pyelonephritis  fre- 
quently follows,  and  recurrent  subacute  or  acute  attacks  occur  from 
time  to  time.  The  renal  symptoms  are  very  slight.  There  may 
be  aching  in  one  kidney,  but  the  organ  is  not  tender  or  enlarged. 
The  urine  is  abundant,  pale,  faintly  acid,  and  hazy  with  pus,  and 
contains  small  shreds.  The  pus  settles  in  a  fiat,  creamy,  or  dead- 
white  layer  at  the  bottom  of  the  glass.  Bacilluria  is  seldom  present 
in  the  milder  forms  of  chronic  pyelonephritis,  but  bacteria  are 
plentiful. 

The  chief  complaint  is  of  chronic  vesical  irritation.  There  is. 
increased  frequency  of  micturition,  partly  from  the  polyuria  and 
partly  from  cystitis.  Micturition  is  either  equally  frequent  night 
and  day,  or  the  nocturnal  frequency  is  the  greater.  This  nocturnal 
polyuria  is  very  characteristic  of  chronic  pyelonephritis.  On 
cystoscopy  the  general  surface  of  the  bladder  is  healthy,  or  there 


X]  Hy^MATOGENOUS  pyelonephritis      125 

may  be  a  patchy  cystitis.  The  trigone  is  red  and  often  puffy, 
and  the  inflammation  is  chiefly  confined  to,  or  more  marked  on,  one 
side.  On  this  side,  which  corresponds  to  the  diseased  kidney,  the 
ureteric  orifice  is  surrounded  by  a  zone  of  inflammation,  and  not 
infrequently  an  irregular  greyish  patch  may  be  seen  below  it,  repre- 
senting a  delicate  film  of  necrosis  of  the  surface  epithehum.  In 
the  more  chronic  conditions  these  appearances  may  be  absent, 
there  is  congestion  at  the  bladder  base,  and  the  opening  of  the 
ureter  appears  a  little  thickened  and  reddened.  The  efflux  from 
the  ureter  of  the  diseased  side  is  abundant  and  cloudy  with  pus. 
In  very  chronic  cases  it  is  often  scanty  and  thick,  and  occasion- 
ally it  is  reduced  to  a  putty-like  pipe  of  pus  which  is  squeezed 
out  of  the  ureter  at  long  intervals.     (Plate  5,  Fig.  2.) 

In  other  cases  the  vesical  symptoms  are  prominent,  and  the 
case  is  frequently  regarded  as  one  of  chronic  cystitis.  There 
is  frequent  and  painful  micturition.  The  urine  contains  mucus 
and  bladder  epithelium,  bacilluria  is  usually  present,  and  the 
urine  has  a  fishy  and  sometimes  an  ammoniacal  smell.  In  these 
cases  recurrent  attacks  of  subacute  or  acute  pyelonephritis  fre- 
quently occur.  In  some  cases  there  are  recurrent  attacks  of 
urethritis. 

In  another  class  of  cases  the  bladder  is  healthy,  there  is  a  long 
history  of  renal  aching  but  no  enlargement  or  tenderness.  The 
urine  contains  a  few  bacteria  and  some  pus,  and  the  ureteric 
catheter  shows  that  these  come  from  one  kidney.  The  quantity 
of  urine  is  continuously  lowered  (8  to  10  oz.  in  twenty-four  hours), 
and  there  are  recurrent  attacks  of  complete  anuria  lasting  for 
twenty- four  to  thirty-six  hours. 

Diagnosis. — In  fulminating  cases  the  symptoms  are  those  of 
a  sudden  and  profound  toxgemia.  Infective  endocarditis,  acute 
influenza,  the  onset  of  lobar  pneumonia,  and  malaria  have  been 
diagnosed  in  such  cases.  Examination  of  the  urine  usually  makes 
the  diagnosis  plain. 

In  acute  cases  the  abdominal  pain  and  rigidity  of  the  muscles 
have  led  to  the  mistaken  diagnosis  of  cholecystitis,  subphrenic 
abscess,  abscess  of  the  liver,  appendicitis  -with  retrocoHc  abscess. 
The  discovery  of  a  large  tender  kidney,  together  with  changes  in 
the  urine,  will  lead  to  a  correct  diagnosis. 

Rarely  an  exploratory  laparotomy  may  be  necessary  to  clear 
up  the  diagnosis. 

In  chronic  pyelonephritis  the  most  frequent  mistake  in  diag- 
nosis is  to  regard  the  chronic  cystitis  as  primary  and  to  overlook 
the  renal  infection.  The  diagnosis  is  made  by  the  cystoscope 
and    by   examining  the   urine   dra^vTi   from  each  kidney  by  the 


126  THE   KIDNEY  [chap. 

ureteric  catheter.  All  subacute  and  chronic  cases  of  pyelonephritis 
should  be  examined  with  the  X-rays  for  calculus. 

Prognosis. — In  mild  cases  of  acute  pyelonephritis  the  prognosis 
is  good.  Recovery  without  operation  is  the  rule.  Recurrent  attacks 
occur,  however,  and  in  a  large  percentage  of  cases  bacilluria  and 
slight  chronic  pyelitis  or  pyelonephritis  persists.  This  may  dis- 
appear, or  it  may  continue  for  many  years,  and  may  be  the  cause 
of  an  acute  attack  ten  or  twelve  years  after  the  first. 

In  acute  cases  the  prognosis  is  very  grave,  and  operation  will 
frequently  be  necessary.  In  fulminating  cases  the  issue  is  often 
fatal.  If  the  diagnosis  has  been  made,  an  early  operation  gives  a 
more  hopeful  outlook.  Chronic  pyelonephritis  persists  for  many 
years,  and  eventually  destroys  the  kidney.  There  is  the  danger 
of  secondary  stone  formation  in  the  kidney  and  bladder,  and  of 
ascending  pyelonephritis  of  the  second  kidney. 

Treatment. — The  treatment  is  medicinal,  serum,  vaccine,  or 
operative. 

Medicinal  treatment  consists  in  confining  the  patient  to  bed 
and  applying  hot  fomentations  to  relieve  pain,  and  turpentine 
stupes  or  dry  cupping  over  the  loins  to  reheve  congestion.  Urinary 
antiseptics  should  be  given,  such  as  urotropine,  metramine,  hetra- 
lin,  or  helmitol  in  doses  of  5  or  10  gr.  every  four  hours.  Alkalis 
and  diuretics  should  be  freely  administered,  such  as  potassium 
citrate  in  doses  of  50  or  60  gr.  daily,  Contrexeville  water  and  dis- 
tilled water.  The  bowels  should  be  freely  opened,  and  calomel 
given  in  doses  of  ^V  ^o  i  g^-  thrice  daily.  This  treatment  is  suit- 
able for  mild  cases  and  the  early  stage  of  acute  cases.  If  bacteria 
persist  in  the  urine  when  the  acute  symptoms  have  subsided, 
urinary  antiseptic  treatment  should  be  continued  and  vaccine 
treatment  adopted. 

Serum  treatment. — This  consists  in  the  injection  of  serum, 
usually  anti-colon-bacillus  serum,  since  in  the  great  majority  of 
cases  the  infection  is  due  to  the  bacillus  coli.  A  dose  of  25  c.c.  is 
injected  hypodermically  each  day  for  three  days,  and  at  the  same 
time  calcium  lactate  in  doses  of  20  gr.  thrice  daily  is  given  by  the 
mouth  in  order  to  prevent  the  joint-pains  and  rashes  which  may 
result  from  the  serum.  Should  no  effect  be  produced  in  three 
days,  the  treatment  should  be  abandoned.  Dudgeon  obtained 
satisfactory  results  in  most  instances  by  this  treatment  in  12  cases 
of  acute  pyelonephritis.  In  5  of  his  cases  the  effect  was  rapid  and 
permanent,  in  4  there  was  considerable  benefit,  in  3  there  was  no 
benefit.     In  chronic  cases  the  treatment  has  no  effect. 

Vaccine  treatment. — This  consists  in  injecting  graduated 
doses  of  dead  bacteria  obtained  from  cultures  of  the  patient's  urine, 


X]  H.^MATOGENOUS  PYELONEPHRITIS       127 

or  of  a  stock  vaccine  should  there  not  be  time  for  the  preparation 
of  an  autovaccine.  Small  doses  of  two  or  three  million  colon  bacilli 
should  be  used  at  first,  and  repeated  in  four  or  five  days,  rising 
rapidly  to  10,  15,  20,  25.  30  millions,  and  so  on  to  100  millions, 
then  to  150  millions  for  six  doses,,  then  200  millions  for  six  or 
twelve  doses.  The  injection  should  be  made  once  a  week  after 
the  first  three  doses ;  and  should  any  reaction,  shown  by  a  rise 
of  temperature,  malaise,  and  headache,  occur^  the  dose  should  be 
reduced  and  a  longer  interval  allowed. 

In  acute  cases  the  results  of  the  vaccine  treatment  have  been 
unsatisfactory.  In  10  cases-only  one  showed  a  change  in  tempera- 
ture (Williamson) ;  in  a  large  number  of  patients  treated  by  Dudgeon 
there  was  "  no  material  improvement  except  in  a  very  few  in- 
stances." In  chronic  cases,  with  or  without  acute  exacerbations, 
where  no  complication,  such  as  growth  or  stone,  is  present,  the 
treatment  may  be  of  great  service  and  bring  about  a  cure  when 
all  other  methods  have  failed.  The  treatment  is  a  long  and  tedious 
one,  and  may  last  for  six  months  or  a  year  or  even  longer.  The 
doses  must  be  carefully  graduated  and  sudden  large  increases 
avoided,  as  an  overdose  is  frequently  followed  by  a  recurrence  of 
symptoms,  and  if  this  has  occurred  the  vaccine  appears  to  have 
less  effect.  In  several  cases  under  my  care  the  urine  has  been 
rendered  sterile  after  six  or  twelve  months'  treatment. 

Operative  treatment. — The  operations  that  have  been  per- 
formed are  nephrotomy,  decapsulation  and  opening  of  surface 
abscesses,  partial  resection,  and  nephrectomy,  but  only  nephrotomy 
and  nephrectomy  need  be  considered. 

I  have  collected  40  cases  of  operation  in  acute  hsematogenous 
pyelonephritis  from  the  literature,  with  the  following  results  : — 

Unilateral  Operations            Cases  Recovered    No  change  Died 

Nephrotomy 12  . .  3         . ,         2         . .  7 

Decapsulation    and    opening 

of  surface  abscesses        ..6  ..  6         ..         0         ..  0 

Partial  resection        ..          ..2  ..  2         ..         0         ..  0 

Nephrectomy             . .         . .     17  . .  17        . .        0        . .  0 

Bilateral  operations 
Nephrotomy   ..  ..  ..2         ..  2         ..         0         ..         0 

Nephrectomy     and     nephro- 
tomy         1         ..  1         ..         0         ..         0 

40  31  2  7 

The  results  of  nephrotomy  are  even  less  satisfactory  than  this 
table  shows.  I  have  performed  the  operation  twice  in  the  acute 
stage,    and    seen   three   cases  in   which   it   had  previously    been 


128  THE   KIDNEY  [chap. 

performed.  All  these  patients  survived.  This  makes  20  cases  of 
nephrotomy  with  7  deaths.  The  after-results  of  nephrotomy  are 
unsatisfactory.  Chronic  pyelonephritis  persists,  and  nephrectomy 
may  be  required  at  a  later  date. 

The  best  results  in  acute  cases  have  been  obtained  by  nephrec- 
tomy. This  should  not  be  too  long  delayed.  If  at  the  end  of 
five  or  seven  days  the  acute  symptoms  persist  and  the  patient  is 
beginning  to  lose  ground,  nephrectomy  should  be  performed. 

In  chronic  cases  operation  will  be  called  for  on  account  of 
recurrent  exacerbations  of  acute  inflammation,  or  of  persistent 
cystitis,  or  for  secondary  calculus,  or  sometimes  for  anuria  If 
the  second  kidney  is  shown  to  be  healthy  by  examination  of  its 
urine,  nephrectomy  should  be  performed.  I  have  found  nephro- 
tomy sufficient  when  reflex  oliguria  and  attacks  of  anuria  were 
caused  by  chronic  unilateral  pyelonephritis. 

LITERATURE 

Adams,  Joum.  Amer.  Med.   Assoc,  1899,  xxxiii.  1512. 

Barnard,  Lancet,  Oct.  28,  1905. 

Brewer,  A7in.  Surg.,  Dec,  1904,  p.  1010  ;   Surg.,  Gyn.,  and  Obst., 

June,  1908,  p,  699. 
Dudgeon,  Lancet,  1908,  i.  616. 
Finkelstein,  Jahrb.  /.  Kind.,  1896,  xliii.  148. 
Guyon  et  Albarran,  Arch,  de  Med.  Exper.,  1897. 
Herringham,  Clin.  Joum.,  1910,  xxxv.  241. 
Legueu,  Ann.  d.  Mai.  d.  Org.  Gen.-Vrin.,  1904,  xxii.  1441. 
Lenhardt,  Milnch.  med.  Woch.,  1907,  Nr.  16. 
Pawlowsky,  Zeits.  f.  Hyg.  u.  Infect.,  1900,  xxxiii.  261. 
Pousson,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1902,  p.  514. 
RoUeston,  Pract.,  April,  1910,  p.  439. 

Sampson,  Johns  Hopkins  Hosp.  Bull.,  1903,  No.  153,  p.  336. 
Walker,  Thomson,  Pract.,  May,  1911  ;  Renal  Function  in  Urinary 

Surgery.    1908. 

2.  Secondary  or  Ascending-  Pyelonephritis 

This  disease  results  from  an  extension  of  infection  from  the 
lower  urinary  organs.  It  is  the  last  phase  of  many  chronic  dis- 
eases of  the  bladder  and  urethra,  such  as  malignant  growths^ 
stone,  enlarged  prostate,  stricture.  It  frequently  follows  surgical 
interference  in  the  bladder  or  urethra,  such  as  the  passage  of  instru- 
ments, or  operations  upon  stone,  and  for  this  reason  has  been 
termed  "  surgical  kidney."  Ascending  pyelonephritis  usually,  but 
not  invariably,  attacks  kidneys  which  are  already  the  seat  of 
chronic  aseptic  pyelonephritis  due  to  obstruction  in  the  lower 
urinary  tract.     (Plates  6,  7.) 

Etiology. — The  bacteria  already  mentioned  are  the  active 
agents  in  the  production  of  ascending  pyelonephritis.  They  are 
introduced   into    the    bladder   by   a   sound   or   other   instrument 


Ascending  pyelonephritis  in  case  of  enlarged  prostate. 

(Pp.   128,  130.) 


Plate  6 


x]  ASCENDING   PYELONEPHRITIS  l^'J 

wliicli   has  not  been  sterilized,   or  they  may  be  carried  from  an 
infected  nrethra  on  a  sterilized  instrument. 

Infection  from  the  bladder  may  reach  the  kidney  by  the 
following  paths  : — 

1.  Blood-vessels. 

(a)  General  circulation. 

(6)  Anastomosis  between  the  vesical,  uterine,   ovarian, 

and  renal  arteries  (Sampson), 
(c)  Along  the  blood-vessels  of  the  ureter. 

2.  Lymphatics  of  the  ureter  in  the  muscular  and  outer  coats, 
3;  Ureter. 

Infection  ascending  along  the  ureter  is  the  most  frequent 
method.  It  spreads  either  by  chrect  continuity  of  the  inflam- 
matory process  or  by  ascent  of  motile  bacteria  against  the  stream 
of  urine. 

The  presence  of  organisms  in  the  bladder,  or  even  in  the  ureter, 
is  not  necessarily  followed  by  an  ascending  infection  of  the  kidney, 
Albarran  injected  cultures  of  virulent  organisms  into  the  blad.der 
and  ureter  without  producing  ascending  pyelonephritis. 

There  are  natural  barriers  to  the  ascent  of  infection.  The 
lower  end  of  the  ureter  penetrates  the  wall  of  the  bladder  very 
obliquely,  and  its  longitudinal  layer  of  niuscle  passes  into  the 
trigone.  When  the  bladder  is  distended  the  trigone  is  pushed 
down  and  the  bladder  wall  stretched  so  that  the  intramural  por- 
tion of  the  ureter  becomes  more  oblique  and  flattened  by  stretch- 
ing, and  the  intravesical  tension  further  closes  the  lumen  by  pres- 
sure. When  the  bladder  is  contracted  the  intramural  portion 
becomes  shortened  and  less  oblique,  but  the  mucous  membrane 
is  thrown  into  folds,  which  prevent  a  reflux  of  fluid.  The  condi- 
tion under  which  a  reflux  is  most  likely  to  occur  is  during  a  powerful 
contraction  of  the  bladder  when  the  organ  contains  a  small  quan- 
tity of  fluid.  The  downward  flow  of  urine  is  a  further  protection 
against  the  ascent  of  bacteria.  The  predisposing  causes  of  ascend- 
ing infection  are  urethral  obstruction,  long-continued  cystitis,  new 
growths  of  the  bladder,  operations  on  the  bladder  involving  the 
ureteric  orifice,  and  stone  in  the  bladder  or  ureter,  all  of  which 
destroy  the  natural  barriers. 

Pathology. — In  the  early  stage  ascending  pyelonephritis  is 
frequently  unilateral ;  in  the  later  stages  it  is  invariably  bilateral, 
although  one  side  is  more  diseased  than  the  other.  The  disease 
is  bilateral  in  83  })er  cent,  of  cases. 

'i'hree  types  of  ])athological  change  are  found  : 

1.  Recent  acute  pyelonephritis. — The  kidney  is  enlarged, 
tense,  and  deeply  congested.  Scattered  over  the  surface  are  small 
J 


130 


THE  KIDNEY 


[chap. 


groups  of  greyish-yellow  spots  the  size  of  a  pin's  head  or  a  split 
pea,  or  larger,  and  shghtly  raised.  The  kidney  substance  is  dark 
and  congested,  and  greyish  streaks  radiate  outwards  through  the 
pyramids  and  cortex.  A  greyish-yellow  patch  underlies  the  raised 
surface  nodule.     Ecchymoses  are  observed  here  and  there. 

2.  Old-standing,    diffuse,    subacute,    and    chronic    pyelo- 


Fig.  28. — Microscopical  section  of  kidney  in  suppurative 
pyelonephritis. 

The  field  shows  the  edge  of  the  affected  area  and  illustrates  the  spread  of  inflammation 
along  the  line  of  the  tubules. 

nephritis. — The  kidney  is  enlarged,  and  has  a  mottled  dull-red 
and  greyish-yellow  surface.  Section  shows  either  a  uniform  dull 
greyish-yellow  appearance  or  patches  of  this  colour  scattered  on  a 
dull-red  surface.  (Plates  6,  7.)  Small  points  of  softening  may  be 
found  in  the  cortex.  The  grey  streaks  and  patches  consist  of  dense 
round-cell  infiltration.  (Fig.  28.)  Bacteria  are  found  in  the 
straight  and  convoluted  tubules  and  passing  through  the  walls. 


ASCENDING  PYELONEPHRITIS 


l.U 


•i.  Old-standing  sclerotic  pyelonephritis.— The  kidney  is 
of  iiatinal  size  or  smaller  than  iioniial.  It  is  surrouiHled  by  a 
dense  tliick  layer  of  fibro-lipomatous  tissue  firmly  adherent  to  the 
capsule.  The  capsule  is  usually  adherent  to  the  kidney.  The 
surface  is  irregular  and  granular.  The  kidney  substance  is  tough 
and  fibrous.  Microscopically  there  is  diffuse  chronic  interstitial 
fibrosis.  The  tubules  are  widely  separated,  some  foiniing  small 
cysts  and  others  being  broken  up  and  disintegrated.  Patches  of 
round-cell  infiltration  are  found  here  and  there.  Many  sclerosed 
glomeruli  are  seen.  The  ureter  may  be  almost  normal,  or  may 
be  dilated,  thickened,  and  thrown  into  folds.  The  pelvis  is  thick- 
ened and  may  be  slightly  dilated,  and  contains  purulent  urine. 

Symptoms. — During  the  course  of  chronic  cystitis  or  some 
obstructive  disease,  and  usually  as  a  direct  consequence  of  surgical 
intervention,  such  as  the  passage  of  instruments  or  the  removal 


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:  vV\/  "^-^^.K  .^t^^^A^..^^-^^r\^J 

Chart  14. — Continuous  subnormal  temperature  in  chronic 
ascending  pyelonephritis  in  vesical  calculus. 

of  an  enlarged  prostate,  symptoms  of  acute  infective  pyelonephritis 
supervene.  The  onset  of  chronic  pyelonephritis  is  insidious,  and 
the  symptoms  may  be  insignificant,  so  that  it  is  usually  impossible 
to  say  when  the  disease  commenced.  Occasionally  the  onset  is 
marked  by  an  acute  attack,  which  subsides. 

1.  Acute  ascending  pyelonephritis. — A  few  hours  after 
surgical  interference,  or  sometimes  after  exposure  to  cold,  there 
is  a  rigor,  and  the  temperature  rises  to  102°  or  104°  F.  (Chart  3, 
p.  15).  The  temperature  may,  however,  be  continuously  sub- 
normal (Chart  14).  The  patient  is  drowsy,  and  complains  of 
backache,  sometimes  more  marked  on  one  side.  The  skin  is  dry 
and  harsh,  the  face  heavy  and  apathetic.  There  is  burning 
thirst,  the  mouth  is  dry  and  parched  :  the  toiiguc  is  dry,  red, 
and  glazed  ;  later  it  becomes  coveicd  with  a  brown  or  black  fur 
C' parrot  tongue  ").  Nausea  and  vomiting  are  frequent  symptoms, 
and  there  is  absolute  constipation.     The  abdomen  becomes  tense 


132  THE   KIDNEY  [chap. 

and  distended  with  flatus.  Hiccough  sets  in  and  becomes  in- 
creasingly troublesome.  Rigidity  of  the  abdominal  muscles  is 
usually  present,  and  often  more  marked  on  one  side.  There  is 
tenderness  over  both  kidneys  at  first,  but  after  twenty-four  hours 
this  usually  becomes  confined  to  one  side.  The  tender  kidney  is 
enlarged,  the  second  kidney  is  not  palpable.  There  has  frequently 
been  polyuria  before  the  attack,  and  now  the  urine  suddenly  be- 
comes scanty,  or  there  is  complete  suppression.  The  temperature 
may  remain  at  102°  F.  or  over,  or  it  may  fall,  and  rise  again  after 
another  rigor,  and  then  become  high  and  swinging  while  the  rigors 
are  repeated  at  irregular  intervals.  Herpes  of  the  lips  is  frequently 
observed. 

The  patient  becomes  more  and  more  drowsy,  the  abdominal 
distension  increases,  vomiting  grows  more  frequent,  and  hiccough 
is  constant.  The  pupils  are  small  and  react  sluggishly  to  light. 
Convulsions  are  extremely  rare.  Ursemic  dyspnoea  may  be  present 
and  is  occasionally  paroxysmal.  Cheyne-Stokes  breathing  may 
be  observed  in  the  last  stages.  Muttering  delirium  supervenes, 
and  the  patient  passes  into  coma  and  dies.  Occasionally  the 
mind  remains  clear  and  the  patient  is  restless  and  anxious  ;  the 
temperature  is  high  (105°  F.)  and  swinging,  the  urine  absolutely 
suppressed.     Later  there  is  dehrium,  and  eventually  coma. 

In  less  severe  cases  the  excretion  of  urine  becomes  re-established. 
It  is  scanty  at  first  and  may  contain  blood.  The  temperature 
falls,  flatus  is  passed  and  the  abdominal  distension  disappears,  and 
the  symptoms  subside. 

In  other  acute  cases  the  urine  continues  to  be  secreted  in 
good  quantity,  but  there  are  recurrent  attacks  of  very  severe 
haemorrhage. 

In  mild  cases  the  temperature  rises  to  102°  or  103°  F.  after  a 
slight  chill,  the  quantity  of  urine  is  reduced,  and  there  are  slight 
tenderness  over  the  kidneys,  headache,  nausea,  and  sometimes 
vomiting.  The  bowels  are  constipated.  The  urine  becomes 
purulent.  In  some  cases  the  urine  becomes  foul  and  there  are 
signs  of  cystitis  without  any  rise  of  temperature.  As  the  cystitis 
subsides,  blood  begins  to  appear  in  the  urine,  and  on  cystoscopy 
the  haemorrhage  is  found  to  be  renal.  In  this  type  severe  haemor- 
rhage may  continue  until  relieved  by  operation. 

2.  Chronic  suppurative  pyelonephritis. — An  acute  attack 
of  septic  pyelonephritis  which  subsides  is  usually  followed  by 
chronic  septic  pyelonephritis.  In  rare  cases,  where  the  obstruction 
ill  the  lower  urinary  tract  is  relieved,  the  kidneys  may  return  to 
their  normal  state. 

The  onset  of  chronic  suppurative  pyelonephritis  is  frequently 


Dilatation  of  renal  pelvis,  pyelitis,  and  suppurative  nephritis  in  en- 
larged prostate.     Same  kidney  as  shown  in  Plate  6.     (Pp.  128,  130.) 


Plate  7. 


x"l 


ASCENDING   PYELONEPHRITIS 


133 


insidious.  I  (  is  ciii^rat'tcd  on  chronic  ascpl  ic  pycloncpliiil  is  (p.  II  7), 
anil  it.  is  ollcn  impossible  to  state;  when  the  septic  coniphcation 
ensued.  Wlieii  the  syndrome  is  fully  developed,  the  condition  is 
known  as  urituiry  scpticn'mui.  The  patient  has  a  sallow,  earthy 
appearance,  the  skin  is  dry  and  harsh  and  seldom  sweats.  There 
is  gradual,  persistent  loss  of  weight.  The  lips  are  dry ;  the  tongue 
is  at  first  dry  along  the  middle,  then  over  the  whole  surface,  and 
it  becomes  glazed,  red,  and  cracked;  the  mouth  and  throat  also 
become  dry.  There  are  loss  of  appetite,  dyspepsia,  and  occasion- 
ally nausea.  The  bowels  are  constipated.  The  patient  suffers 
from  frontal  headache,  and  is  frequently  drowsy.  There  is  polyuria, 
amounting  to  80-100  oz.  in  twenty-four  hours.  The  urine  is  pale, 
neutral  or    faintly  acid,    has  a    specific  gravity  of    1008-1010,  or 

NOyEMaEK  


DATE 

a 

5 

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// 

/2 

13 

11- 

15 

16 

'^ 

ja 

19 

20 

21 

22 

23 

24- 

25 

26 

27 

f 
I03° 

I02° 

lO  1  ° 
IOO° 
9  9° 
SB° 

3  7° 
96° 

A 

( 

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t 

V 

'•-v 

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1 

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v-.- 

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^ 

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*-V 

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v. 

Chart  15. — Continuous  subnormal  temperature  in  case  of 
bladder  growth  with  chronic  septic  pyelonephritis. 

even  less.  It  is  hazy  and  contains  flakes,  and  may  occasionally 
give  the  characteristic  drift-cloud  appearance  of  bacilluria.  There 
is  a  trace  of  albumin,  and  a  small  deposit  of  pus  which  settles  as 
a  thin  creamy  layer.  The  urine  contains  pus,  sometimes  a  few 
casts,  and  bacteria.  There  may  be  slight  renal  aching,  but  the 
kidneys  are  not  enlarged  or  tender. 

There  is  frequent  micturition,  in  increased  quantity,  more 
marked  at  night  (nocturnal  polyuria),  but  this  symptom  may  be 
masked  by  the  symptoms  of  previously  existing  prostatic  or  bladder 
disease.  The  temperature  varies  from  97°  to  97'6°  or  97*8°  F., 
occasionally  rising  to  98°  or  to  normal.     (Charts  14,  15.) 

An  injection  of  methylene  blue  either  fails  to  colour  the  urine 
or  the  elimination  is  delayed,  reduced,  and  prolonged. 

After  the  injection  of  phloridzin,  either  no  sugar  is  produced  by 
the  kidneys,  or  only  a  trace. 


134  THE   KIDNEY  [chap. 

The  course  of  chronic  septic  pyelonephritis  may  be  interrupted 
by  acute  or  subacute  attacks  at  long  or  short  intervals.  (Chart  4, 
p.  16.)  These  are  brought  on  by  the  passage  of  an  instrument 
or  by  injudicious  exposure  to  cold  and  fatigue,  or  may  come  on 
apparently  without  exciting  cause.  Such  an-  attack  resembles  the 
acute  attacks  already  described,  but  is  usually  milder  in  character. 
During  the  attacks  the  quantity  of  urine  diminishes,  and  there  may 
even  be  a  period  of  temporary  suppression,  lasting  some  hours, 
and  the  patient  rapidly  emaciates.  After  the  attack  improvement 
takes  place,  the  urine  is  secreted  in  as  great  quantity  as  before,  but 
the  patient  has  lost  ground.  Sometimes  the  patient  dies  during 
an  acute  exacerbation. 

Chronic  septic  pyelonephritis  may  last  several  years,  and  its 
progress  apart  from  acute  exacerbations  is  slowly  progressive.  In 
the  later  stages  the  quantity  of  urine  diminishes,  and  the  headache, 
thirst,  anorexia,  drowsiness,  and  other  symptoms  increase.  There 
are  seldom^  if  ever,  ursemic  convulsions.  The  patient  may  die 
almost  suddenly  without  an  increase  in  the  symptoms,  or  may 
gradually  sink  with  a  failing  renal  function. 

Diagnosis. — The  occurrence  of  acute  symptoms  such  as  those 
detailed  above,  after  the  passage  of  an  instrument  in  a  case  of 
obstructive  urinary  disease,  presents  no  difficulty  in  diagnosis. 

If  the  urine  becomes  clear  while  the  temperature  remains  high 
and  swinging  and  the  kidney  large,  it  is  likely  that  a  pyonephrosis 
has  developed. 

The  diagnosis  of  chronic  suppurative  pyelonephritis  is  of  high 
importance  in  diseases  of  the  urethra,  prostate,  and  bladder.  The 
symptoms  are  insidious  and  slight,  and  must  be  carefully  investi- 
gated. The  condition  of  the  urine  is  very  important  in  diagnosis. 
The  tests  for  the  renal  function  are  also  invaluable.  Where  opera- 
tive treatment  of  the  renal  disease  is  proposed,  it  will  be  necessary 
to  catheterize  the  ureters  and  examine  each  urine  separately. 

Prognosis. — Many  patients  die  during  the  acute  attack  of 
ascending  pyelonephritis,  and  of  those  that  recover  the  majority 
suffer  from  chronic  pyelonephritis.  Should  the  urinary  obstruc- 
tion be  removed,,  the  further  progress  of  the  disease  will  probably 
be  arrested,  but  the  kidneys  are  permanently  damaged. 

Chronic  ascending  pyelonephritis  is  usually  slowly  progressive, 
and  is  eventually  fatal  after  some  years. 

Treatment.  1.  Acute  ascending  pyelonephritis. — Prophy- 
lactic measures  include  the  sterilization  of  all  urethral  instruments 
and  of  all  basins,  syringes,  lotions,  etc.,  and  the  cleansing  of  the 
surgeon's  hands  and  of  the  patient.  They  consist  also  in  prac- 
tising  the   utmost   gentleness   in   all    manipulations.     Koughness 


X]  asgi:nding  pyeloni:fhkitis  155 

nicjiiis  hi'uisiiit,'  jiiid  liicci'alioii,  and  Ibis,  togctlici"  witli  lln"  damage 
produced  by  ohsl ruction.,  paves  Mie  way  for  sepsis. 

Non-operfUwe  tredtment  consists  in  dry  cupping,  hot  fomenta- 
tions, turpentine  stupes,  or  poultices  applied  to  the  loin  to  relieve 
the  renal  congestion.  A  hot  pack  or  hot  vapour  bath  should  be 
given  to  induce  sweating.  Pilocarpine  may  be  injected  hypodermic- 
ally,  but  should  be  carefully  watched.  It  is  important  to  get  the 
bowels  opened  and  to  relieve  the  abdominal  distension.  A  large 
dose  of  castor  oil  or  a  strong  saline  purge  should  be  given,  but  it 
is  frequently  returned  if  the  patient  has  commenced  vomiting. 
Turpentine  and  soap-and-water  enemata,  to  which  20  minims  of 
oil  of  rue  are  added,  help  to  bring  away  flatus,  and  a  rectal  tube 
should  be  introduced  high  up  in  the  rectum. 

If  the  patient  is  able  to  keep  fluids  down,  large  draughts  of  warm 
Contrexeville  water  should  be  given,  and  may  be  combined  with 
theocin  sodium  acetate  3-8  gr.  every  four  hours,  or  theobromine 
sodiosalicylate  (diuretin)  10  or  15  gr.  every  four  hours.  Pituitary 
(infundibular)  extract  (20  per  cent.,  B.,  W.  &  Co.)  may  be  used 
in  a  dose  of  0-5  c.c.  This  has  the  advantage  of  being  given  sub- 
cutaneously,  but  its  powerful  effect  in  raising  the  blood  pressure 
necessitates  great  caution  in  its  use;  I  combine  it  with  atropine. 
Glucose  solution  should  be  introduced  into  the  subcutaneous 
tissues  in  large  quantities,  several  pints  being  injected  slowly. 
Infusion  of  glucose  solution  (2|  per  cent.)  into  a  vein  (median 
basihc)  is  the  most  rapid  and  powerful  means  of  re-estabhshing 
the  renal  secretion.     Two  or  three  pints  are  infused. 

Operative  treatment. — There  are  two  indications  for  operative 
treatment : 

i.  The  rehef  of  urinary  obstruction,  if  present, 
ii.  The  relief  of  congestion  and  drainage  of  the  kidney. 

Should  the  measures  detailed  above  prove  ineffectual  and  no 
improvement  be  apparent  in  two  or  three  days,  or  if  the  patient 
appear  to  be  failing  before  this,  operation  will  become  necessary. 

If  there  is  unrelieved  urinary  obstruction,  this  should  first 
receive  attention.  The  operation  which  is  performed  for  the  relief 
of  the  obstruction  is  not  necessarily  that  which  would  have  been 
chosen  had  no  kidney  complication  developed.  The  operation 
should  give  the  freest  drainage  with  the  least  amount  of  shock. 
Suprapubic  cystotomy  and  drainage  with  a  large  tube  are  the  best 
means  of  carrying  this  out.  It  is  a  temporary  measure.  Opera- 
tion for  the  permanent  cure  of  the  obstruction  can  be  performed 
later  if  the  patient  survives.  , 

For  relief  of  the  renal  congestion  and  sepsis  nephrotomy  should 
be  performed.     The  kidney  is  freely  incised  along  the  convex  border, 


136  THE   KIDNEY  [chap. 

and  a  large  rubber  drain  introduced  into  the  pelvis.  If  there  is 
free  hseniorrhage  a  mattress  stitch  may  be  inserted  to  control  it, 
the  rest  of  the  kidney  wound  being  left  open  or  packed  with  anti- 
septic gauze.  Another  large  drain  is  placed  outside  the  kidney 
before  uniting  the  edges  of  the  parietal  wound.  As  a  result  of 
this  operation  the  temperature  falls  to  normal,  and  within  a  few 
hours  the  dressings  are  flooded  with  urine.  The  temperature  may 
remain  normal  and  the  progress  to  complete  recovery  be  iminter- 
rupted,  or  the  temperature  may  rise  again  to  100°  or  101°  F.  for 
a  few  days  and  then  gradually  fall.  The  secretion  of  urine, 
however,  is  re-established,  and  the  crisis  is   over. 

It  is  of  vital  importance  that  these  operations  be  carried  out 
with  the  utmost  celerity.  The  operation  for  obstruction  and  that 
for  relief  of  the  renal  congestion  and  sepsis  are  done  at  one  sitting. 
Saline  infusion,  rectal  and  intravenous,  should  be  given  on  the 
return  from  the  operation.  There  is  some  danger  of  haemorrhage 
from  the  kidney  about  the  seventh  or  tenth  day  after  operation. 
Should  this  occur,  the  tube  is  removed  and  the  kidney  rapidly 
plugged  with  gauze.  I  have  operated  in  this  manner  with  suc- 
cessful results  on  patients  who  were  weakened  by  over-long  delay, 
on  others  in  the  final  unconscious  stage  of  the  disease,  and  on  a 
patient  mth  one  kidney,  anuric  for  three  days  and  with  a  tempera- 
ture of  106°.  F. 

Nephrectomy  is  not  indicated  in  these  cases,  since  nephrotomy 
suffices  to  tide  over  the  crisis ;  the  shock  in  nephrectomy  is  greater, 
the  disease  is  not  cured  by  it,  and  the  second  kidney,  if  it  is  not 
acutely  septic,  is  damaged  to  an  unknown  degree  by  back  pressure. 
Nephrectomy  may,  however,  be  necessary  in  the  hsemorrhagic 
type  of  pyelonephritis  on  account  of  the  severe  and  continuous 
haemorrhage. 

2.  Chronic  ascending  pyelonephritis. — In  the  majority  of 
cases  chronic  ascending  pyelonephritis  is  bilateral,  one  kidney, 
however,  being  more  seriously  damaged  than  the  other.  The 
prophylaxis  of  chronic  ascending  pyelonephritis  consists  in  the 
early  removal  of  enlarged  prostate,  the  efficient  treatment  of 
stricture,  the  removal  of  calculi,  and  other  measures  directed 
against  the  existence  of  chronic  obstruction  and  chronic  sepsis 
in  the  lower  urinary  organs. 

When  chronic  pyelonephritis  has  become  established,  operative 
interference  in  the  bladder  and  urethra'  must  be  undertaken  with 
the  utmost  caution.  When  an  operation  for  enlarged  prostate  is 
proposed  the  bladder  should  be  opened  suprapubically  and  drained 
for  a  week  or  more  before  the  prostate  is  removed.  In  a  case  of 
stricture,  external  urethrotomy  with  drainage  of  the  bladder  would 


X]  ASCENDINCi    PVFLONHPHKITIS  137 

be  prclci'icd  to  iii((MiKil  uid  lirofoiiix'  or  dilatation  with  in.slruiiients. 
Urinary  antiseptics  {sec  uikUh-  Ha'niatogeiious  Pyelonephritis, 
p.   r2())  and  dinrctics  should  be  freely  administered. 

If  the  disease  is  proved  to  be  unilateral  and  the  second  kidney 
ascertained  to  be  healthy  by  means  of  the  ureteric  catheter  and 
tests  for  the  renal  function,  the  kidney  may.  after  removal  of  all 
lower  urinary  obstruction,  be  incised  or  removed.  It  is  seldom, 
however,  that  these  circumstances  combine  to  make  surgical  inter- 
vention possible. 

Vaccine   treatment    has    not    given    encouraging   results.      The 

administration  of  renal  extract  has  been  tried  in  these  cases  and 

in  chronic  aseptic  pyelonephritis.     It  does  not  influence  the  cause, 

or,  in  the  cases  I  have  seen  treated  by  it,  modify  the  progress  of 

the  disease. 

LITERATURE 

Albarran,  Tmite  de  C'himrgie  (Le  Dentu  et  Delbet),  iii.  7G0. 

Israel,    N ierenhrayikheiten.     Berlin,   1901. 

Legueu,  Bull,  de  la  Soc.  de  C'hir.,  1901. 

Pousson,  Folia  'Urol.,  Jan.,  1909,  p.  445. 

Sampson,  Johns  Hopkins  Hosp.  Bull.,  Dec,  190,3. 

Walker,  Thomson,  Pract.,  June,  1903. 

Weir,  Med.  Bee,  1894,  xl.  32,'j. 

Wilms,  Miinch.  med.   Woch.,  1902,  Xr.  12,  p.  470. 


CHAPTER  XI 

SURGICAL  INFLAMMATION  OF  THE  KIDNEY 
AND  PELVIS  (Concluded) 

PYELITIS 

The  intimate  relation  between  the  kidney  and  its  pelvis  makes 
it  impossible  for  severe  inflammation  to  be  wholly  confined  to  one 
or  the  other.  At  the  same  time  there  are  cases  where  the  brunt 
of  the  inflammation  falls  upon  the  pelvis,  and  the  kidney  is  but 
slightly  involved,  so  that  clinical  evidence  of  nephritis  cannot  be 
obtained.  These  are  cases  of  mild  subacute  or  chronic  inflamma- 
tion, which  may  either  follow  upon  an  acute  attack  of  pyelo- 
nephritis or  arise  de  novo. 

Etiology. — -Mid-adult  life  is  most  frequently  affected  in  either 
sex.  The  infection  may  be  blood-borne  (haematogenous),  or  it 
may  ascend  from  the  lower  urinary  organs  by  the  ureter  or  the 
lymphatics  of  the  ureter. 

As  in  pyelonephritis,  diseases  of  the  lower  urinary  organs  which 
cause  obstrucFion  and  inflammation  are  the  most  frequent  causes. 
Thiis,  enlarged  prostate,  stricture,  stone  in  the  bladder,  gonorrhoea 
(T8~ per  cenK— Finger),  Hadder  growths,  etc.,  are  predisposing 
causes. 

"  in  one  class  of  cases  a  calculus  is  present  in  the  pelvis.  This 
may  be  either  the  cause  or  the  result  of  the  pyelitis. 

Pathology. — The  mucous  membrane  in  slight  catarrhal  forms 
is  hypereemic,  and  in  more  severe  forms  is  thickened  and  velvety, 
and  sometimes  shows  petechise  and  superficial  ulceration.  In  old- 
standing  pyelitis,  especially  where  calculi  are  present,  the  wall  of 
the  pelvis  is  thick  and  leathery,  the  mucous  membrane  dull  and 
opaque,  sometimes  there  are  small  colloid-filled  cysts  {'pyelitis 
cystica),  or  tiny  sago-grain  lymph  follicles  {pyelitis  granulosa). 
Pyelitis,  whether  ascending  or  hsematogenous,  may  be  unilateral. 
In  the  later  stages  of  ascending  pyelitis  the  condition  is  usually 
bilateral. 

Symptoms. — In  cases  of  non-calculous  pyelitis  the  symptoms 
are  usually  insignificant,  if  the  cases  of  acute  pyelonephritis,  already 

138 


CHAP.  x[]  PYELITIS :    SYMPTOMS  139 

described,  arc  cxcliidcd.     Tlicic  may  hr  a  sliiflil,  ri,s(!  of  teniperatiirc 
to  100'  F.  at  Jii<,'lii,  hut  i\w  tcnipciuturt'  is  oltcii  uiiaft'ected. 

Slight  constant  renal  achirifr  is  complained  of,  either  at  the 
angle  formed  by  the  last  rib  and  the  erector  spina?  mass  of  muscles, 
or  anteriorly  a  little  below  and  internal  to  the  tip  of  the  9th  rib. 
There  may  be  a  little  tenderness  on  pressure  at  this  point,  but 
often  this  is  absent.     The  kidney  is  not  enlarged. 

Urine. — Changes  in  the  urine  form  the  most  important  signs 
of  pyelitis.  There  is  polyuria,  most  marked  at  night.  The  urine 
is  pale  and  opalescent,  the  specific  gravity  low  (1008  or  1010). 
It  is  acid  and  usually  odourless,  but  sometimes  there  is  the  stale- 
fish  smell  of  bacilluria. 

On  standing  the  urine  deposits  a  fiat,  creamy  layer  of  pus,  which 
moves  heavily  when  the  glass  is  tilted.  The  supernatant  fluid 
is  pale  and  cloudy,  and  there  may  be  the  characteristic  drift-cloud 
appearance  on  making  the  urine  circulate  in  a  glass.  There  is  a 
slight  cloud  of  albumin.  Microscopically,  tailed  cells  and  over- 
lapping epithelial  cells. (see  under  Pyuria,  p.  147)  are  present,  but 
no  tube  casts.     Bacteria  are  present  and  may  be  abundant. 

With  the  cystoscope  the  ureteric  efflux  is  copious,  frequently 
repeated,  and  cloudy  to  a  varying  degree.  The  movements  at 
the  ureteric  orifice  are  vigorous.  The  edges  of  the  orifice  may 
be  healthy,  but  are  frequently  reddened  and  sometimes  thick. 
(Plate  16,  Fig.  1,  facing  p.  234.)  A  halo  of  congestion  or  inflam- 
mation may  surround  the  orifice  in  an  otherwise  healthy  bladder. 
Where  cystitis  is  present  these  appearances  may  be  obscured, 
and  there  may  be  nothing  apart  from  the  efflux  to  distinguish 
one  orifice  from  the  other  when  the  disease  is  imilateral.  In 
slight  degrees  of  pyelitis  the  urine  shows  only  a  faint  haze  and  a 
few  flakes,  and  the  cystoscopic  changes  consist  in  a  faint  blush 
around  the  orifice,  which  is  open  and  with  sHghtly  thickened  lips. 

It  will  sometimes  be  found  on  examination  of  the  urine  of  each 
kidney,  drawn  by  a  ureteric  catheter,  that  the  urine  of  the  diseased 
pelvis  is  alkaline,  while  that  of  the  healthy  side  is  acid.  The  blend 
of  the  two  urines  is  acid  if  alkaline  cystitis  is  not  present. 

In  cases  where  pyelitis  is  secondary  to  cystitis,  the  symptoms 
of  the  latter  may  obscure  those  due  to  the  pyelitis.  In  this  case 
the  urine  may  be  alkaline  and  stinking  and  ammoniacal.  It  con- 
tains pus  and  mucus,  giving  the  deposit  a  billowy  appearance. 

Diagrnosis. — In  making  a  diagnosis  the  following  questions  must 
be  answered : — 

1.  In  a  case  of  cystitis  from  any  cause  is  pyelitis  present  ? 

2.  Where  pyelitis  is  present  is  the  kidney  involved  ? 

3.  Is  there  a  calculus  in  the  renal  pelvis  ? 


140  THE   KIDNEY  [chap. 

1.  Where  the  signs  of  pyeHtis  are  obscured  by  cystitis  the 
diagnosis  depends  upon  the  cloudy  efflux  from  the  ureteric  orifice, 
the  appearance  of  the  orifice,  and  the  examination  of  the  urine  of 
each  kidney  obtained  by  the  ureteric  catheter. 

2.  It  is  often  extremely  difficult  to  state  whether  the  kidney  is 
involved  in  a  slight  chronic  pyelitis.  The  history  of  a  severe  acute 
onset  points  to  renal  inflammation,  and  so  do  tenderness  and 
enlargement  of  the  organ,  an  excessive  quantity  of  albumin,  the 
discovery  of  tube  casts,  and  proofs  of  an  inadequate  renal  function 
as  shown  by  symptoms  {see  under  Chronic  Pyelonephritis,  p.  117) 
and  by  the  methylene-blue  and  phloridzin  tests. 

3.  There,  may  be  difficulty  in  the  diagnosis  of  a  pelvic  calculus 
when  there  has  been  no  pain  or  hsematuria  and  no  history  of  stone. 
The  X-rays  will  settle  the  diagnosis. 

Treatment. — The  first  indication  for  treatment  is  to  remove 
any  local  irritant  or  any  cause  of  back  pressure  or  sepsis  in  the 
lower  urinary  organs. 

The  removal  of  a  calculus  from  the  renal  pelvis  may  suffice 
to  cure  the  pyelitis. 

Enlarged  prostate  and  stricture  must  be  treated.  If  the 
pyelitis  is  of  long  standing  and  there  is  reason  to  suspect  that 
the  kidney  is  involved,  it  may  be  necessary  to  drain  the  bladder 
by  suprapubic  cystotomy  for  a  fortnight  or  more  before  proceed- 
ing to  the  operation  for  radical  cure  of  the  prostatic  obstruction. 

The  treatment  of  the  pyeHtis  consists  in  the  administration  of 
urinary  antiseptics  (urotropine,  hetralin,  helmitol,  metramine,  etc.) 
and  diuretics  (Contrexeville,  Evian,  Vittel,  and  other  alkaline 
diuretic  waters). 

Vaccine  treatment  should  be  tried  in  chronic  cases  {see  under 
Pyelonephritis,  p.  126). 

Instillations  of  argyrol  and  other  silver  preparations  have  been 
made  through  a  ureteric  catheter  passed  along  the  ureter  into  the 
renal  pelvis.  The  method  is  not  free  from  the  danger  of  obstruction 
resulting  from  swelling  of  the  mucous  membrane  at  the  outlet  of 
the  pelvis,  and  should  be  used  with  the  utmost  caution,  and  not 
practised  if  the  temperature  be  elevated.  Kelly  and  Casper  have 
employed  this  method  in  cases  of  chronic  gonorrhceal  pyelitis,  and 
Stockmann  recommends  it  in  all  cases  of  chronic  pyehtis.  From 
10  to  15  c.c.  of  a  1-2  per  cent,  solution  of  nitrate  of  silver  are 
instilled  into  the  renal  pelvis  on  several  successive  days  or  on 
alternate  days,  or  a  solution  of  1  in  2,000  to  1  in  1,000  may  be 
used  in  larger  quantities. 

My  experience  of  this  method  has  been  favourable.  I  reserve 
it  for  cases  where  medicinal  and  vaccine  treatment  have  failed. 


XI]  PYELITIS  OF  INFANCY  Ml 

It  should  only  be  used  by  those  who  are  experienced  in  ureteral 
catheterization. 

Should  these  methods  fail  in  chronic  cases,  and  diuretics  and 
urinary  antiseptics  fail  in  more  severe  and  acute  cases,  the  kidney 
should  be  exposed  and  opened,  and  the  pelvis  washed  out  and 
drained  through  the  wound.  A  small  rubber  tube  may  be  fixed 
in  the  pelvis  by  a  catgut  stitch  through  the  renal  capsule,  and  the 
pelvis  washed  with  silver  nitrate  solution  daily  for  ten  days,  when 
the  wound  is  allowed  to  close.  The  cystitis  should  then  be  treated 
by  bladder-washing. 

Pyelitis  of  Infancy  and  Childhood 

A  form  of  acute  pyelitis  which  occurs  in  infants  and  children 
merits  separate  discussion. 

Many  of  the  cases  are  met  with  in  infants  under  2  years,  but 
the  disease  also  occurs  in  older  children.  Dr.  J.  Thomson  records 
8  cases  at  the  ages  of  7i,  10,  10,  12,  14,  14,  18,  20  months. 

The  majority  are  girls,  but  cases  in  boys  have  been  recorded, 
and  Morse  found  that  40  per  cent,  of  his  50  cases  were  boys. 

Constipation  is  very  frequently  present,  and  there  may  have 
been  occasional  attacks  of  diarrhoea.  There  is  frequently  a  history 
of  soreness  around  the  anus,  painful  defsecation,  or  blood  in  the 
motions.  The  symptoms  begin  suddenly  with  a  rise  of  temperature 
and  a  chill  or  rigor,  which  may  be  severe  and  repeated.  Delirium, 
squinting,  and  vomiting  follow,  and  the  child  is  restless  and  dis- 
tressed. The  temperature  is  high,  104°  or  106°  F.,  and  remittent 
in  type.     There  is  pallor  and  anorexia.     Emaciation  is  slow. 

The  local  symptoms  may  be  slight  and  insignificant.  Attacks 
of  screaming — due  to  colic — occur,  and  tenderness  on  palpation 
in  the  region  of  the  kidney  has  been  suspected  in  some  cases. 
Increased  frequency  of  and  pain  on  micturition  is .  sometimes 
observed,  but  this  symptom  may  be  wanting,  and  occasionally  the 
urine  is  held  for  an  unusually  long  time  to  avoid  pain  on  passing 
it  if  there  is  soreness  of  the  vulva. 

The  first  indication  that  there  is  any  urinary  trouble  is  often 
given  by  a  yellowish  staining  of  the  diapers.  The  urine  is  strongly 
acid.  There  is  a  little  albumin  (usually  less  than  0"1  per  cent.), 
while  pus  is  present  in  considerable  amount.  Hyaline  and  finely 
granular  tube  casts  are  occasionally  found.  Red  blood-corpuscles 
may  be  seen  in  the  early  stage.  Some  epithelial  cells  from  the 
kidney  pelvis  or  quantities  of  squamous  cells  from  the  bladder 
are  ])resent,  and  bacteria  in  large  numbers,  which  are  found  to  bo 
the  bacillus  coli  in  the  majority  of  cases,  but  occasionally  the 
staphylo-  or  streptococcus. 


U2  THE   KIDNEY  [chap. 

Diagnosis. — This  depends  upon  the  presence  of  pus  and  bacteria 
in  the  urine.  Thomson  looks  upon  pyrexia  "  and  extreme  distress 
without  any  other  symptoms  sufficient  to  produce  them,"  and  the 
occurrence  of  rigors,  in  a  child  under  2  years,  when  malaria  can  he 
excluded,  as  important  points  in  diagnosis. 

The  condition  has  been  mistaken  for  malaria,  irregular  typhoid, 
and  general  tuberculosis. 

Prognosis. — There  is  a  tendency  to  spontaneous  recovery,  but 
the  condition  sometimes  ends  fatally.  The  cases  improve  rapidly 
under  treatment.  The  temperature  falls  and  the  symptoms  subside 
in  a  week  or  ten  days.  The  pus  may  remain  for  several  weeks 
and  the  bacteria  for  longer. 

Treatment. — Acidity  of  the  urine  is  reduced  by  the  adminis- 
tration of  alkalis,  and  the  urine  is  kept  neutral.  Citrate  of  potash 
is  given  in  doses  of  24  gr.,  or  in  severe  cases  36  to  48  gr.,  per  day 
in  infusion  of  digitalis,  and  continued  till  danger  of  a  relapse  is 
past.  Urotropine,  5  or  10  gr.  daily,  and  salol  may  be  given  in 
addition  to  the  alkaline  treatment. 

The  nurse  should  be  warned  not  to  wipe  soiled  diapers  against 
the  urethra. 

Operative  measures  are  very  rarely  necessary.  If  the  child  is 
steadily  losing  ground  under  medicinal  treatment,  and  the  symp- 
toms are  unilateral,  nephrotomy  may  be  performed. 

Pyelitis  (Pyelonephritis)  of  Pregnancy 

When  pyelonephritis  is  already  present  the  effect  of  pregnancy 
is  to  aggravate  the  disease.  Pyelonephritis  not  infrequently 
develops  during  the  early  months  of  pregnancy,  and  the  pregnancy 
is  the  predisposing  cause  of  the  disease. 

Pathology. — The  bacteriology  is  similar  to  that  of  other  renal 
infections.     Albeck  found  the  bacillus  coli  in  131  out  of  159  cases. 

The  right  kidney  is  almost  always  attacked  (65  in  70  cases — 
Legueu),  and  the  condition  is  unilateral.  The  disease  most  fre- 
quently appears  about  the  fourth  month  of  pregnancy. 

It  has  been  ascribed  to  compression  of  the  ureter  by  the  gravid 
uterus,  but  this  is  doubtful,  since  the  uterus  is  not  likely  at  this 
early  stage  to  cause  pressure.  Mirabeau  holds  that  it  is  due  to 
hypergemia  of  the  vesical  mucous  membrane  and  the  altered  rela- 
tions of  the  ureters  and  bladder  to  the  urethra  causing  urinary 
obstruction. 

When  an  instrument  has  been  passed  the  infection  is  usually 
looked  upon  as  ascending.  In  other  cases  when  no  infection  of 
the  lower  urinary  tract  has  occurred,  it  is  considered  to  be  a 
hsematogenous  infection. 


xij  PYELITIS   OF   PREGNANCY  143 

Symptoms. — Bar  describes  a  latent  presuppurative  stage  during 
which  there  is  bacilhiria  with  continuous  fever,  but  Legueu  found 
a  sudden  onset  in  12  out  of  70  cases.  There  are  a  rigor  and  rise  of 
temperature,  together  with  severe  unilateral  renal  pain  in  paroxysms 
and  frequent  painful  micturition.  The  vesical  irritation  may  be  the 
first  and  most  distressing  symptom.  The  urine  contains  pus  and 
bacteria.  The  quantity  of  pus  is  not  a  gauge  of  the  severity  of 
the  infection,  and  Legueu  states  that  the  urine  may  be  almost 
clear  even  with  grave  symptoms.  The  general  condition  usually 
remains  good,  although  the  temperature  is  high  and  swinging. 
In  a  few  cases  the  disease  is  bilateral  and  there  is  rapid  emaciation, 
with  drowsiness,  burning  thirst,  dry  tongue,  and  other  signs  of 
uraemia.  In  the  later  stages  of  pregnancy  palpation  of  the  abdomen 
is  difficult  owing  to  the  large  volume  of  the  uterus.  There  is  some 
rigidity  on  one  side,  and  the  kidney  is  tender ;  it  may  be  felt 
slightly  enlarged. 

Diagnosis. — The  diagnosis  depends  upon  the  examination  of 
the  urine  and  the  situation  of  pain  and  tenderness.  A  mistaken 
diagnosis  of  appendicitis  has  been  made. 

Course  and  prognosis.  Effect  on  the  pregnancy  and 
puerperium. — Of  52  untreated  cases,  premature  labour  occurred 
in  13  (25  per  cent.)  (Legueu).  When  the  acute  attack  occurs 
early  in  the  pregnancy  and  there  is  an  interval  of  normal  tem- 
perature before  jparturition  takes  place,  the  puerperium  is  usually 
apyretic.  If,  however,  the  acute  attack  is  late  in  the  pregnancy 
there  is  usually  fever  during  the  puerperium,  but  puerperal  infec- 
tion does  not  occur. 

Effect  on  the  child. — If  the  pregnancy  be  interrupted  the 
child  is  usually  ill-nourished,  and  dies  in  one-third  of  cases  (Legueu). 
If  the  attack  occur  late,  and  the  pregnancy  go  on  to  full  term,  the 
child  is  usually  healthy  and  well-nourished. 

Effect  on  the  kidney. — After  parturition  the  pyelonephritis 
may  subside  and  the  urine  clear  and  become  sterile,  but  more 
frequently  bacilluria  and  some  degree  of  pyelonephritis  persist  and 
exacerbations  occur  during  succeeding  pregnancies. 

Treatment. — Prophylaxis  consists  in  careful  asepsis  in  catheter- 
ization and  in  the  treatment  of  constipation  during  pregnancy.  If 
bacilluria  exists  or  there  is  chronic  pyelonephritis,  this  should  be 
energetically  treated,  and  the  patient  warned  of  the  danger  of 
becoming  pregnant.  The  production  of  abortion  or  the  induction 
of  premature  labour  is  seldom  necessary,  but  it  may  be  called  for 
in  a  severe  case.  Urinary  antiseptics  tiiid  vac<;ine  treatment  should 
be  given,  and  in  the  great  majority  of  cases  these  yield  satis- 
factory results.     {See  Pyelonephritis,  p.  126.) 


144  THE   KIDNEY  [chap. 

Operative  treatment. — This  is  very  rarely  necessary.  Nephrotomy 
has  given  good  results,  and  is  specially  indicated  when  the  pyelo- 
nephritis is  unilateral.  In  severe  bilateral  pyelonephritis  premature 
labour  should  be  induced.  Nephrectomy  is  a  more  severe  operation. 
It  may  be  necessary  in  unilateral  pyelonephritis,  and  does  not 
affect  the  course  of  the  pregnancy  in  most  cases. 

Cova  collected  21  cases  of  nephrectomy,  and  found  that  the 
pregnancy  went  on  to  term  in  15  and  was  5  times  interrupted 
spontaneously  and  once  artificially.  The  mortality  is  9-5  per  cent. 
According  to  this  observer  nephrectomy  is  well  borne  in  the  early 
months  of  pregnancy,  but  less  so  after  the  fifth  month. 

LITERATURE 

Albeck,  Zeits.  f.  Geb.  u.  Gyn.,  Ix.  466. 

Ayres,  Amer.  Journ.   Urol.,  1906,  p.  480. 

Bar,  Soc.  d'Obst.  de  Paris,  June  16,  1904. 

Box,  Lancet,  1908,  i.  77. 

Casper,  Wien.  med.  Press,  1895,  p.  1417. 

Cova,  Soc.  d'Obst.  e  di  Gin.,  1903,  p.  692. 

Cumston,    Amer.  Journ.  Med.  Sci.,  1908,  p.  87. 

Johnson,  Amer.  Journ.   Urol.,  1906,  p.  566. 

Legueu,   Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1904,  p.  1441. 

Morse,   Amer.  Journ.  Med.  Sci.,  1909,  p.  313. 

Pousson,  Folia   Urol.,  1909,  p.  445. 

Sampson,  Johns  Hopkins  Hasp.  Bidl.,  1903,  p.  336. 

Sellei  und  Unterberg,  Berl.  Min.  Woch.,  1907,  p.  1113. 

Smith,  Bellingham,  Gui/s  Hosp.  Repts.,  1906,  p.  227. 

Thomson,  Scot.  Med.  Surg.  Jour7i,,  1902,  p.  7. 

PYONEPHROSIS 

Pyonephrosis  is  distension  of  the  kidney  and  its  pelvis  with 
pus  or  purulent  urine.  In  the  description  of  pyelonephritis  it  was 
pointed  out  that  obstruction  in  the  lower  urinary  organs  was  a 
frequent  predisposing  factor,  and  that  some  dilatation  of  the  renal 
pelvis  was  almost  constant  in  these  cases.  The  degree  of  dilatation 
is,  however,  very  slight,  and  the  destruction  of  renal  tissue  by 
intrapelvic  pressure  is  minimal.  In  pyonephrosis  the  kidney  tissue 
is  destroyed  by  intrapelvic  pressure,  and  the  presence  of  sepsis 
may  be  accidental. 

There  are  two  distinct  forms  of  pyonephrosis  : 

1.  Pyonephrosis  secondary  to  uronephrosis  (hydronephrosis), 

or  uro-pyonephrosis. 

2.  Pyonephrosis  developing  from  acute  pyelonephritis. 
Etiology. — The  etiology  of  uro-pyonephrosis  is  that  of  uro- 
nephrosis. The  condition  is  unilateral,  it  occurs  more  often  on 
the  right  side,  it  is  more  cDmmon  in  women,  and  it  is  in  most 
cases  related  to  movable  kidney,  stone,  or  pregnancy.  The  actual 
obstruction  is  usually  situated  high  up  in  the  ureter,  and  is  due 


XI]  PYONEPHROSIS  145 

to  a  stone,  or  to  strictiu'o  oi-  duplicatioii  of  tlie  ureter.  The  super- 
added infection  may  })e  a.scendiii*,',  from  leceiit  cystitis,  or  it  may 
be  lianuatogenous. 

Pyonephrosis  developing  in  acute  pyelonephritis  occurs  especi- 
ally in  cases  of  old-standing  disease  of  the  lower  urinary  organs, 
such  as  enlarged  prostate,  stricture,  and  growths  of  the  bladder 
and  prostate,  and  is  therefore  more  frequent  in  men.  The  infec- 
tion is  almost  invariably  ascending.  There  is  frequently  bilateral 
disease,  but  the  second  kidney  is  not  necessarily  pyonephrotic. 
The  obstruction  which  gives  rise  to  the  dilatation  of  the  kidney 
is  at  any  part  of  the  ureter,  and  is  due  either  to  stricture  or  to 
swelling  of  the  mucous  membrane  consequent  upon  the  septic 
inflammation.  The  bacteria  are  those  of  other  renal  suppurations. 
Anaerobic  bacteria  are  sometimes  found. 

A  pyonephrosis  is  ''  open  "  when  the  obstruction  is  incomplete 
and  pus  escapes,  and  "  closed  "  when  the  block  is  complete. 

Pathology. — The  dilated  kidney  forms  a  globular  or  elongated 
mass.  It  frequently  r-eaches  the  size  of  a  child's  head  and  fills  the 
flank  and  one  side  of  the  abdomen. 

The  pelvis  may  be  greatly  dilated  and  form  a  large  globular 
swelling,  which  is  capped  by  a  slightly  enlarged  kidney.  This 
form  is  said  to  occur  especially  where  the  pyonephrosis  is  of 
ascending  origin.  The  kidney  may  be  greatly  distended,  form- 
ing the  pouch,  while  the  pelvis  is  small  and  hidden.  The  surface 
shows  rounded  grey  or  dark  bosses  corresponding  to  saccules  in 
the  pouch  and  separated  by  grooves  corresponding  to  septa  between 
these.  The  kidney  is  firmly  adherent  to  its  surroundings,  and  is 
frequently  hidden  by  a  thick  fibro-fatty  layer.  There  is  a  single 
large  cavity  in  the  centre  formed  by  the  dilated  pelvis  or  the  greatly 
distended  sinus  of  the  organ,  and  with  this  numerous  pouches  com- 
nninicate.  These  pouches  are  separated  by  firm  fibrous  septa  of 
varying  thickness,  and  frequently  communicate  with  each  other. 
Sometimes  the  communication  of  a  pouch  with  the  main  cavity  is 
very  small,  and  occasionally  a  pouch  may  become  completely  shut 
off  from  the  central  cavity.  In  the  walls  of  the  secondary  pouches 
there  may  be  small  abscess  cavities. 

The  lining  membrane  of  the  primary  and  secondary  pouches  is 
smooth  and  tough,  and  is  occasionally  covered  with  a  rough  greyish 
false  membrane,  which  may  be  gritty  with  calcareous  deposit. 
The  distension  of  the  kidney  is  brought  about  by  pressure  upon 
the  pyramids,  which  become  flattened  and  then  pouched,  while 
the  colunms  of  Bertini  form  the  fibrous  septa.  These  septa  may 
become  thinned  out  so  that  one  pouch  communicates  with  another. 
Microscopical  examination  of  the  wall  of  the  sac  shows  remains  of 


146  THE   KIDNEY  [chap. 

the  renal  parenchyma.  The  glomeruli  are  fibrous,  and  the  tubules 
undergoing  atrophy.  There  is  widespread  fibrosis,  and  scattered 
through  this  are  patches  and  areas  of  recent  leucocytic  infiltra- 
tion. Albarran  has  described  areas  of  compensatory  hypertrophy. 
Partial  pyonephrosis  may  occur,  and  is  due  to  the  blocking  of 
one  section  of  a  dichotomous  renal  pelvis.  A  small  portion  or 
one  pole  of  the  kidney  may  be  converted  into  a  pyonephrosis  by 
the  blockage  of  one  or  several  calyces  with  a  stone.  The  content 
of  a  pure  pyonephrosis  is  pus,  and  this  is  sometimes  thick  and 
almost  cheesy.  Traces  of  urea  may  be  found,  but  are  occasionally 
absent.  In  a  uro-pyonephrosis  the  contents  are  urine  with  a 
varying  admixture  of  pus. 

Calculi  may  be  present  in  the  sac,  and  may  be  primary  and 
cause  the  obstruction,  or  secondary.  When  the  pyonephrosis  is 
secondary  to  disease  of  the  lower  urinary  organs  the  ureter  is  large, 
elongated,  tortuous,  greatly  dilated  and  pouched,  and  usually 
adherent  to  the  surrounding  cellular  tissue ;  the  wall  is  thick  and 
tough,  and  there  are  folds  and  strictures  which  may  be  so  narrow 
as  to  admit  only  a  fine  probe.  When  the  pyonephrosis  follows 
a  uronephrosis  or  a  descending  infection,  only  the  part  of  the 
ureter  above  the  site  of  obstruction  is  damaged.  The  ureter  is 
inserted  into  the  dilated  pelvis  at  a  point  high  above  the  lowest 
part  of  that  receptacle,  and  may  be  adherent  to  the  surface  of 
the  sac. 

The  functional  power  of  the  renal  tissue  of  a  pyonephrotic 
kidney  may  have  been  entirely  destroyed,  and  only  pus  is  discharged 
on  nephrotomy.  Usually,  however,  a  certain  quantity  of  urea 
(Albarran  states  2  to  4  gr.  per  litre)  is  found  in  the  fluid  discharged 
by  the  fistula,  and  most  pyonephrotic  kidneys  have  some  amount 
of  functional  power. 

The  second  kidney. — When  the  pyonephrosis  is  due  to  old- 
standing  disease  of  the  lower  urinary  organs,  both  kidneys  are 
usually  affected,  although  in  different  degrees.  Gosset  has  shown 
that  the  lesion  is  occasionally  unilateral  in  these  cases.  When 
bilateral  disease  is  present,  the  second  kidney  usually  suffers  from 
chronic  pyelonephritis,  and  there  is  seldom  any  marked  develop- 
ment of  compensatory  hypertrophy. 

In  uro-pyonephrosis  the  second  kidney  is  usually  healthy,  and 
shows  compensatory  hypertrophy. 

Symptoms. — When  the  pyonephrosis  is  secondary  to  lower 
urinary  disease,  the  symptoms  of  cystitis  or  obstruction  ma;y  obscure 
those  of  the  renal  complication.  Usually,  however,  there  are  symp- 
toms of  ascending  pyelonephritis.  It  may  be  difficult  or  impossible 
to  say  when   obstruction  converts  the  pyelonephritis  into  pyo- 


XI]  PYONEPHROSIS  H7 

nephrosis.  When  the  condition  settles  down  into  a  less  acute 
state,  the  diagnosis  is  more  readily  made. 

The  advent  of  suppuration  in  a  case  of  hydronephrosis  is 
heralded  by  a  rigor,  rise  of  temperature,  and  other  signs  of 
infection. 

The  symptoms  of  pyonephrosis  are  pain  and  tenderness  of  the 
kidney,  tumour,  and  pyuria. 

Pain. — At  the  outset  pain  is  usually  pronounced.  It  is  con- 
stant, heavy,  and  boring,  and  is  occasionally  severe.  When  the 
pyonephrosis  is  more  fully  developed  pain  may  be  absent,  and 
may  occur  only  when  the  outlet  of  the  pyonephrosis  becomes 
blocked  and  the  kidney  fills  up  with  pus.  It  may  then  be  severe 
and  radiate  down  the  ureter,  causing  renal  colic.  The  thigh  is 
often  flexed  to  relax  the  psoas  muscle. 

Tenderness  on  palpation  is  pronounced  at  first,  but  later  it  may 
be  absent,  and  only  appear  during  a  crisis  of  retention.  When 
present  the  abdominal  muscles  are  contracted.  Guyon  found 
tenderness  absent  in  "17  out  of  26  cases. 

Tumour. — The  tumour  has  the  characteristics  of  a  renal 
tumour.  It  projects  below  the  costal  margin,  but,  as  Albarran 
points  out,  it  is  more  likely  than  a  hydronephrosis  to  form  adhe- 
sions and  remain  bound  down  and  concealed  beneath  the  ribs. 
It  forms  a  large,  smooth,  regular,  non-fluctuating,  firm  tumour 
from  which  ballottement  can  be  obtained.  During  an  attack  of 
retention  it  becomes  tense,  larger,  and  tender. 

The  ureter  may  occasionally  be  felt  as  it  crosses  the  brim  of 
the  pelvis,  and  it  may  be  detected  as  a  thickened  band  in  the 
lateral  fornix  of  the  vagina  in  the  female,  or  in  the  rectum  in 
the  male. 

Pyuria. — This  is  the  cardinal  symptom  of  pyonephrosis.  The 
pus  forms  a  thick,  heavy  deposit,  and  the  supernatant  urine  remains 
cloudy.  The  pyuria  is  abundant,  and  is  subject  to  shght  variations 
in  quantity  from  day  to  day,  and  to  intermissions  lasting  a  few 
days.  These  variations  are  dependent  upon  the  ease  with  which 
the  pus  escapes  from  the  pyonephrosis. 

There  are  recurrent  attacks  of  complete  retention  of  pus,  during 
which  the  urine  becomes  clear,  the  tumour  increases  in  size  and 
becomes  painful,  tender,  and  more  tense,  and  the  temperature 
rises.  The  attack  lasts  two  or  three  days,  and  then  the  tempera- 
ture falls  suddenly,  the  symptoms  subside,  and  a  large  quantity 
of  pus  appears  in  the  urine. 

Even  in  the  crises  of  acute  retention  the  urine  may  still  con- 
tain pus  derived  either  from  the  bladder  or  from  a  diseased  second 
kidney. 


148  THE   KIDNEY  [chap. 

Cystoscopy. — If  the  infection  has  been  ascending  there  will  be 
chronic  cystitis  and  evidence  of  urethral  obstruction  or  of  bladder 
growth.  The  orifice  of  the  ureter  may  be  lost  among  the  trabeculse 
and  pouches  of  the  bladder.  It  may  be  discovered  on  a  thick  ridge 
and  show  nothing  abnormal,  even  when  the  ureter  and  renal  pelvis 
are  widely  dilated  and  their  walls  greatly  thickened.  (Edema  and 
thickening  of  the  lips  will  denote  inflammation  of  the  ureter. 

The  orifice  is  occasionally  found  open,  round,  and  immobile, 
and  surrounded  by  a  rigid,  thickened  margin,  or  with  a  thick, 
oedematous,  sometimes  ulcerated  edge. 

In  a  closed  pyonephrosis  there  is  no  efflux,  but  there  may  be 
an  occasional  feeble  gaping  movement  at  the  orifice.  In  an  open 
pyonephrosis  the  efflux  varies  according  to  the  contents  of  the 
pyonephrosis.  It  may  consist  of  thick  worm-like  masses  of  semi- 
solid pus  slowly  expressed  from  the  ureter,  or  there  may  be  a 
copious  intermittent  stream  of  watery  pus  or  of  purulent  urine.  A 
forcible  jet  rapidly  repeated  denotes  that  the  ureter  has  retained 
its  muscular  power,  while  a  slow,  continuous  stream  or  a  lazy 
welling  of  fluid  at  long  intervals  shows  that  the  ureter  is  dilated 
and  atonic. 

Catheterization  of  the  ureters  will  determine  whether  an 
obstruction  exists,  and  at  what  level,  and  also  give  information  in 
regard  to  the  presence,  health,  and  function  of  a  second  kidney. 

Course  and  prognosis. — In  rare  cases  the  pyonephrosis 
diminishes  in  size.  It  is  compressed  and  invaded  by  the  peri- 
nephritic  inflammatory  tissue  from  between  the  calyces  and  from 
the  surface,  and  gradually  shrinks,  being  eventually  replaced  by  a 
fibro-fatty  mass.  The  ureter  becomes  obliterated  and  atrophies. 
More  frequently  there  is  perinephritic  suppuration,  and  this  burrows 
in  various  directions  {see  Perinephritic  Abscess,  p.  112),  and  may 
rupture  into  the  lung,  stomach,  peritoneum,  or  on  the  surface. 
The  patient  eventually  dies  of  exhaustion  from  long-continued 
suppuration. 

Diagnosis. — If  the  pyonephrosis  is  closed  the  diagnosis  will 
depend  upon  the  history  of  pyuria,  the  presence  of  cystitis,  symp- 
toms of  septic  absorption,  and  the  presence  of  a  renal  tumour. 
Occasionally  cases  may  be  met  with  in  which  there  has  never  been 
renal  pain  or  other  urinary  symptom. 

When  there  is  pyuria  alone  the  characters  of  the  pyuria  and 
cystoscopy  will  lead  to  a  diagnosis.  When  cystitis  is  superadded 
the  large  quantity  of  pus  in  the  urine  will  suffice  to  distinguish  the 
renal  disease.  When  the  pus  reaches  one-fifth  to  one-sixth  of  the 
whole  urine  it  must  come  from  the  kidney. 

In  two  other  conditions  there  may  be  very  large  quantities  of 


XlJ 


pyoni:piirosis 


Ml) 


])ii.s  ill  I  he  iiiiiit!  ;ii  iiilcrvals,  iiaiudy,  ( I )  a  suppiiral  iii>,' di  vert  iculuin 
of  tlu;  bladder,  and  (2)  a  piiiulcnt  collcftioii  rouiniuiiicatinf^  witli  a 
ureter.  The  use  of  the  cystoscope,  and  if  necessary  the  ureteric 
catheter,  will  distinguish  a  diverticulum  of  the  bladder.  The 
second  condition  is  only  diagnosed  on  operation,  unless  some  point 
in  the  history  of  the  case  reveals  its  nature. 

The  differential  diagnosis  must  be  made  from — 

(1)  Pyeh)nephritis  without  retention.     The  large  quantity  of 

23US  points  to  pyonephrosis,  and  catheterization  of  the 
ureter  will  show  no  obstruction. 

(2)  Tuberculous    pyonephrosis.     The    presence    of    tubercle 

bacilli  in  the  urine  and  of  tuberculous  lesions  elsewhere 
in  the   genital  system,  and   the   general  tests  for  the 
presence  of  tubercle  in  the  body,  will  distinguish  this 
from   pyonephrosis.     In  such  cases  there  is  usually  a 
thick  tuberculous   ureter  which  will   be   diagnosed   by 
abdominal,  vaginal,    or  rectal  palpation   and  with  the 
cystoscope. 
The  functional  value  of  the  pyonephrotic  kidney  and  the  pre- 
sence of  disease  in  the  second  kidney  and  the  functional  power  of 
this  organ  are  estimated  by  catheterization  of  the  ureters.     The 
urine  of   each  kidney  is  examined,  the   quantity,  naked-eye  and 
microscopic   characters,    and  the    presence    of    albumin   and   the 
quantity  of  urea  being  noted.     The  tests  for  the  renal  function 
(phloridzin,  indigo  carmine,  etc.)  are  used  (p.  20). 

The  following  table  gives  the  results  of  the  examination  of  the 
urines  in  a  case  of  calculous  pyonephrosis : — 


Right  Kidney 

Left  Kidney 

(Pyonephrosis)  . 

(Healthy) 

Quantity 

206-5  c.c. 

107  c.c. 

Specific  gravity 

1004 

1011. 

Freezing-point  (A) 

-0-18°  C. 

-0-76°  C. 

Colour    . . 

Pale,  limpid 

Fairly  coloured. 

Urea 

0-4  per  cent. 

1-3  per  cent. 

Uric  acid 

0-0067  per  cent. 

0-0150  per  cent. 

Chlorides 

0-0977  per  cent. 

01 112  per  cent. 

Phosphates 

0-08  per  cent. 

0-03  per  cent. 

Methylene  lilite .  . 

No  change  in  colour 

Delayed  1  hour  50  min.. 

of  urine 

diminished,    pale 
green,  and  lasted  only 
18  hours. 

Chromogen 

Appeared  25  min., 

Appeared  25  min.. 

small  amount 

large  amount. 

Phloridzin  glycosuria   .  . 

0-395  grm. 

1-623  grm. 

150  THE   KIDNEY  [chap. 

An  X-ray  examination  for  stone  should  be  made  of  the  whole 
urinary  tract,  including  the  bladder,  lower  ureters,  and  second 
kidney. 

Treatment. — The  following  methods  of  treatment  will  be  dis- 
cussed : — 

1.  Drainage  by  ureteral  catheter. 

2.  Plastic  operations. 

3.  Nephrotomy. 

4.  Partial  nephrectomy. 

5.  Nephrectomy. 

1.  Drainage  by  ureteral  catheter. — Pawlik  and  Albarran 
have  advocated  this  method  in  selected  cases.  The  ureter  is 
catheterized  daily  or  less  often,  according  to  whether  a  reaction 
occurs.  The  pelvis  is  washed  at  the  same  time.  The  catheter 
may  be  progressively  increased  in  size  until  No.  13  Fr.  is 
reached.  Albarran  has  left  the  ureteral  catheter  in  place  for 
several  weeks,  changing  it  when  it  became  blocked.  He  uses 
boric  acid,  silver  nitrate  (1  in  1,000),  and  permanganate  of  potash 
(1  in  4,000  to  1  in  500)  for  washing  the  kidney.  Pawlik  recom- 
mends massage  of  the  kidney  and  the  application  of  a  firm  bandage 
afterwards.  He  claims  a  cure  in  a  pyonephrosis  of  150  grm.,  and 
Albarran  another  in  one  of  60  grm. 

Many  circumstances  combine  to  limit  the  application  of  this 
method — an  intolerant  bladder,  febrile  reaction,  strictures  of  the 
ureter,   subdivision  of  the  pyonephrotic  pouch,   the  presence  of 
calculi,  thick  caseous  contents,  etc. — and  there  can  be  very  few ' 
cases  where  it  will  possess  an  advantage  over  an  open  operation. 

2.  Plastic  operations. — In  cases  of  uro-pyonephrosis  plastic 
operations  have  been  undertaken  with  the  object  of  re-establishing 
the  outlet  by  the  ureter.  These  operations  will  be  discussed  under 
Uronephrosis  (p.  179).  It  is  necessary  to  ascertain  first  the  nature 
of  the  obstruction  and  the  functional  power  of  the  kidney,  and 
in  order  to  do  this  a  preHminary  nephrotomy  is  necessary.  Usually 
the  functional  power  is  so  far  destroyed  that  it  is  not  worth  while 
doing  such  an  operation,  and  the  choice  will  lie  between  nephrot- 
omy and  nephrectomy. 

3.  Nephrotomy. — This  may  consist  only  in  incision  of  the 
kidney,  or  an  attempt  may  be  made  to  re-establish  the  lumen  of 
the  ureter. 

The  pyonephrotic  sac  is  opened  by  an  oblique  lumbar  incision. 
The  contents  are  evacuated,  and  septa  between  saccules  are  broken 
down.  Careful  search  is  made  for  interstitial  abscesses  and  the 
main  cavity,  the  upper  portion  of  the  ureter  and  the  subsidiary 
cavities  are  carefully  examined  for  stone,  and  the  perinephrit:ic 


xr]         NEPHROTOMY  FOR  PYONEPHROSIS        151 

tissue  around  llio  kiducy,  and  especially  at  the  upper  and  lower 
poles,  should  he  explored  for  possihle  extrarenal  collections  of  pus. 
Guyon  reconnuends  that  the  edges  of  the  sac  should  be  stitched 
to  the  skin  in  order  to  avoid  perinephritic  suppuration.  This  is 
not  necessary  if  free  drainage  be  established  by  large  rubber  tubes 
placed  both  inside  and  outside  the  kidney. 

This  operation  is  rapid,  causes  no  shock,  and  preserves  the 
remains  of  the  secreting  tissue.  It  may  therefore  be  performed 
in  the  very  worst  cases,  where  the  patient  is  weak  from  severe  or 
prolonged  suppuration,  and  in  cases  where  it  is  impossible  to  esti- 
mate the  value  of  the  second  kidney  or  where  this  organ  is  known 
to  be  the  seat  of  advanced  disease.  The  mortality  of  the  operation 
is  from  17  (Kiister)  to  23-3  per  cent.  (Tuffier). 

After  the  operation  an  improvement  in  the  work  performed 
by  the  second  kidney  is  usually  observed,  and  is  due  to  the  relief 
from  the  depressant  reno-renal  reflex,  and  also  to  the  removal  of 
toxins  which  were  being  absorbed  from  the  pyonephrosis  and 
excreted  by  the  second  kidney.  The  general  health,  for  similar 
reasons,  greatly  improves.  In  27  per  cent.  (Kiister)  of  cases  the 
wound  closes,  the  sac  shrinks,  and  the  patient  is  cured. 

In  a  certain  number  of  cases  septicaemia  persists,  and  the  work 
of  the  second  kidney  is  still  poorly  performed.  This  is  due  to 
continued  suppuration  in  the  thick,  fibrous-walled  cavity,  to  un- 
opened pouches,  to  abscesses  in  the  walls  and  partitions,  to  stones 
being  left  in  the  sac  (16  per  cent,  of  cases),  or  to  the  persistence 
of  the  ureteric  block  and  ureteritis.  A  fistula  remains  in  from 
45*6  per  cent,  (calculous  pyonephrosis  34-2  per  cent.,  non-calculous 
57-1  per  cent. — Tuffier)  to  56  per  cent.  (Kiister). 

Various  means  have  been  adopted  to  obviate  this  or  to  cure 
the  fistula  when  it  has  persisted.  At  the  nephrotomy  Bazy  intro- 
duced a  bougie  along  the  ureter,  and  Doyen  used  a  metal  sound 
to  dilate  the  ureter.  There  is  difficulty,  however,  in  finding  the 
opening  of  the  ureter  in  a  large  multilocular  sac,  and  Albarran 
has  used  the  following  method :  Before  the  nephrotomy  he  passes 
a  catheter  up  the  ureter  by  means  of  the  cystoscope.  At  the 
operation  this  is  easily  found,  and  to  the  end  of  it  is  attached  a 
catheter  of  No.  10  Fr.  size.  By  withdrawing  the  first  catheter  the 
No.  10  catheter  is  drawn  down  to  the  bladder.  This  second  catheter 
is  fixed  to  the  skin  of  the  loin  vnth  a  thread,  and  the  nephrotomy 
is  finished  in  the  manner  described.  The  ureteric  catheter  is  left 
in  place  for  four  or  five  days  and  then  changed.  A  light  pliable 
stilette  is  passed  along  the  catheter,  and  a  metal  conductor  screwed 
on  the  end  of  it.  The  catheter  is  now  withdrawn,  and  replaced  by 
another  which  is  threaded  over  the  guide.     The  ureteral  drainage 


152  THE   KIDNEY  [chap. 

is  continued  for  a  month.  By  this  means  the  number  of  cases 
of  fistula  has  decreased. 

A  fistula  may  be  cured  by  excision  of  its  fibrous  wall,  the 
opening  up  of  the  sac,  removal  of  calculi,  and  the  estabhshment 
of  free  drainage.  Should  these  measures  fail,  the  patient  has  the 
choice  of  retaining  the  fistula  or  having  the  kidney  removed.  The 
presence  of  a  renal  fistula  does  not  of  itself  necessarily  shorten 
life.  Watson  has  described  a  bilateral  renal  fistula  persisting  for 
thirteen  years,  and  Legueu  has  seen  women  become  pregnant  and 
parturition  proceed  naturally  when  such  fistulae  were  present. 
Watson  fits  a  tube  and  metal  reservoir  to  collect  the  urine  dis- 
charged. A  small  celluloid  box  the  shape  of  a  straw  hat  may 
be  used  for  this  purpose.  It  is  held  in  position  by  a  rubber  waist- 
band, and  drains  into  a  receptacle.    (Fig.  32,  p.  159.) 

Secondary  nephrectomy  is  indicated  when  septicaemia  persists  ; 
when  it  is  believed,  from  the  inadequate  secretion  of  the  diseased 
kidney  and  the  absence  of  disease  in  the  second  kidney,  that  a 
depressed  renal  function  in  the  latter  will  improve  after  nephrec- 
tomy ;  and  when  the  patient  is  gradually  losing  ground  from 
prolonged  suppuration. 

The  mortality  of  secondary  nephrectomy  is  only  5*9  per  cent. 
(2  in  25  operations,  8  calculous  and  17  non-calculous — Tuffier).  If 
this  is  added  to  the  mortality  of  nephrotomy  (23-3  per  cent.)  the 
total  mortality  of  nephrotomy  followed  by  nephrectomy  at  a  later 
date  is  29-2  per  cent. 

Nephrectomy. — This  operation  may  be  either  partial  or 
total.  Partial  nephrectomy  is  only  possible  when  there  is  a  partial 
pyonephrosis  with  a  separate  pelvis.     This  condition  is  rare. 

Nephrectomy  is  performed  by  the  lumbar  route.  The  abdominal 
route  has  been  abandoned  owing  to  its  high  mortality  (57  per 
cent. — Kiister). 

Subcapsular  nephrectomy  should  be  performed.  The  kidney 
will  usually  shell  out  of  the  great  perinephritic  fibro-fatty  mass 
with  comparative  ease,  whereas  the  removal  of  the  thick  fibro- 
fatty  capsule  with  the  kidney  is  fraught  with  extreme  difficulty 
and  some  danger.  It  may  be  necessary  to  puncture  a  very  large 
pyonephrosis  with  a  trocar  and  cannula,  and  to  remove  a  large  part 
of  its  contents,  so  as  to  deal  with  the  pedicle  more  easily.  The 
wound  should  be  protected  with  pads,  and  the  patient  turned 
almost  on  his  back  while  the  purulent  fluid  is  being  withdrawn 
through  a  rubber  tube  attached  to  the  cannula.  The  ureter 
should  be  dissected  out  separately,  and  as  much  of  it  removed  as 
possible.  The  mortality  of  this  operation  is  17  per  cent.  (Kiister). 
,  Death  may  take  place  from  shock  in  patients  exhausted  by 


XI I  ri:nal  abscess  i>3 

severe  or  prolonged  suppiiiatioii,  hut  the  ])rii)cipal  danger  is  in- 
adequacy of  the  second  kidney  from  disease  (40  per  cent. — Legueu). 
Nephrectomy  should  not,  therefore,  be  undertaken  until  the  con- 
dition of  the  second  kidney  has  been  ascertained  by  catheteriza- 
tion of  the  ureters  and  the  use  of  the  phloridzin,  indigo-carmine, 
or  methylene-blue  test.  By  this  means  only  those  cases  are  sub- 
mitted to  nephrectomy  in  which  there  is  a  functionally  adequate 
second  kidney,  and  the  mortality  is  thereby  greatly  reduced.  In 
the  remaining  cases  nephrotomy  is  performed,  and  at  a  later  date 
improvement  in  the  condition  of  the  second  kidney  may  render 
nephrectomy  practicable. 

As  to  the  time  when  operation  should  be  performed  in  a  case 
of  pyonephrosis,  Bazy,  Pousson,  and  recently  Morris  have  urged 
the  importance  of  early  nephrotomy  in  all  cases  with  the  view  to 
preventing  irreparable  damage  to  the  kidney. 

LITERATURE 

Albarran,  Traiti  de  Chirurgie  (Le  Dentu  et  Delbet),  viii.  800. 

Bazy,  Xlle  Congres  fran9.  de  Chir.,  Paris,  1898,  p.  'i(\. 

Cahn,  Milnch.  med.  Woch.,  1902,  xlix.  19. 

Casper,   Wieii.  med.  Presse,  1895,  xxxvi.  38. 

Fouguet,  These  de  Paris. 

Gosset,  These  de  Paris,  1900. 

Greaves,  Brit.  Med.  Journ.,  July  13,  1907. 

Halle,  These  de  Paris,  1897. 

Meyer,  Med.   News,  Sept.  12,  1900. 

Morris,  Lancet,  1910,  i.  1597. 

Watson,    Ann.  Surg.,  1908,  No.  3. 


ABSCESS   OF   THE   KIDNEY 

Under  this  term  will  be  described  a  rare  condition  in  which 
there  is  circumscribed  suppuration  in  the  renal  parenchyma,  form- 
ing a  solitary  abscess  of  considerable  size.  From  this  category  are 
excluded  an  abscess  formed  in  a  calyx  plugged  by  a  stone  or 
other  obstruction  {partial  pyonephrosis),  and  scattered  points  of 
suppuration  in  the  kidney  substance  {suppurative  nephritis). 

Etiology  and  pathology. — According  to  Morris,  a  renal  abscess 
may  be  formed  by  {a)  the  fusing  together  of  a  number  of  miliary 
abscesses,  or  (6)  the  plugging  of  a  large  artery  with  a  septic  embolus. 
The  infection  may  be  hsematogenous  in  cases  of  ulcerative  endo- 
carditis or  pyaemia,  or  it  may  be  ascending  from  the  lower  urinary 
tract.  Injury  by  wounds  or  contusions  and  lacerations  and  cal- 
culus of  the  kidney  are  other  causes.  The  abscess  may  rupture 
into  the  renal  pelvis  and  the  pus  be  discharged  from  the  ureter  or 
on  the  surface  of  the  kidney  and  form  a  perinephritic  abscess. 

Symptoms. — The  abscess  may  give  rise  to  acute  or  chronic 


154  THE   KIDNEY  [chap. 

symptoms.  In  acute  cases  the  temperature  rises  after  a  rigor, 
and  there  are  severe  renal  pain,  a)3dominal  rigidity  and  tenderness. 

The  kidney  is  not  sufficiently  enlarged  to  form  a  tumour,  and, 
unless  the  abscess  is  secondary  to  infection  of  the  urinary  tract 
or  bursts  into  the  renal  pelvis,  there  is  no  pus  in  the  urine. 

Morris  states  that  hsematuria  often  precedes  the  formation  of 
abscess,  and,  when  it  does,  partial  suppression  of  urine  may  be 
expected. 

Symptoms  may  be  entirely  absent  in  chronic  abscess  of  the 
kidney,  or  they  may  resemble  those  of  stone. 

Treatment. — The  abscess  will  not  infrequently  be  found  during 
an  exploratory  operation,  but  if  a  diagnosis  has  been  made  the 
kidney  should  be  exposed  without  delay.  The  abscess  should  be 
freely  incised,  and  the  kidney  carefully  searched  for  other  col- 
lections of  pus  and  for  calculi.  Morris  has  excised  portions  of  the 
kidney  in  such  cases.  If  the  kidney  is  extensively  destroyed  it 
must  be  removed,  but  nephrectomy  should  be  reserved  for  cases 
Avhere  the  destruction  of  renal  tissue  is  widespread. 

EENAL  AND   PERIRENAL  FISTULiE 

Eistulse  which  open  on  the  lumbar  region  may  take  origin  in 
the  kidney  or  ureter,  or  they  may  be  unconnected  with  the  urinary 
tract.  In  a  small  number  of  cases  fistulae  connected  with  the  kidney 
appear  spontaneously  or  follow  an  injury.  The  great  majority  of 
renal  and  perirenal  fistulse  follow  upon  an  operation. 

1.  Peeieenal  Fistula  unconnected  with  the  Ueinaey  Oegans 

Perinephritic  abscess,  if  untreated,  ruptures  on  the  skin,  having 
reached  the  surface  by  the  triangle  of  Petit ;  or  it  may  be  incised 
and  a  postoperative  fistula  persist. 

The  origin  of  perinephritic  abscess,  when  the  kidney  is  not 
diseased,  has  been  discussed  (p.  112). 

The  subsequent  fistula  may  be  single,  and  open  in  the  lumbar 
region,  or  there  may  be  several  openings,  which  are  often  connected 
by  subcutaneous  tracks.  A  large  inflammatory  mass  may  surround 
or  displace  the  kidney  (Fig.  29).  There  is  frequently  a  perinephritic 
cavity.  Beyond  this  the  sinus  may  lead  by  a  tortuous  track  through 
the  diaphragm  into  the  pleural  cavity,  into  the  iliac  fossa,  or  else- 
where, according  to  the  origin  of  the  abscess.  The  quantity  of  pus 
which  escapes  varies  at  different  times  in  the  same  individual. 
From  time  to  time  retention  of  pus  may  cause  an  attack  of  pain 
and  fever,  relieved  by  the  discharge  of  a  large  amount  of  pus  from 
the  fistula. 


XI] 


PERIRENAL  FISTULA 


155 


Diagnosis.      TIk'  <>ii,^iiiiil  scat  ot  suppiiratioi)  may  Ix'-  .sliowii  hy 
tlic  hibtoiy  of  the  cusc  or  hy  (lie  presence  ol'  ,seai\s  (Fig.  :}0).     Much 


PLRI  NEPHRITIS 


HIDN£Y 

PUSHED  DOWH 


6INUS     OPEHIHC 
INTO    OLD 
EMPYEMA    CAiflTy 


JIN  US     IN. 
PERINtPHnhlC    W/2£/4 


3IHUS    CONNECTED 
WTH   PERJHEPHRntC 
^REA 


Fig.  29. — Diagram  of  area  of  perinephritic  suppuration 
following  empyema. 

information  can  be  obtained  by  the  injection  into  the  sinus  of  an 
emulsion  of  bismuth  and  then  taking  a  radiogram.     Examination 


/t/iEA      Of 
PERINEPHRITIC 
;'i?f;:  o.  V-  \  iUPPURj^  TIOH 


SC/iR    OF  OLD    OPERATION 


Fig.  30. — Diagram  of  area  of  perinephritic  suppuration 
in  case  of  dermoid  of  kidney. 

Note  the  fistulous  track  passing  beneath  the  iliac  vessels. 


156  THE   KIDNEY  [chap. 

of  the  urine,  cystoscopy,  and  catheterization  of  the  ureter  on  the 
fistulous  side  demonstrate  that  there  is  no  urinary  infection,  and 
that  the  ureter  on  this  side  is  patent  and  the  kidney  active. 

Treatment. — The  treatment  is  surgical,  and  may  require 
extensive  operations,  such  as  the  exploration  of  the  perinephritic 
tissue,  the  search  for  a  retrocaecal  appendix,  or  the  obliteration  of 
a  cavity  in  the  pleura  by  resection  of  ribs.  Before  resorting  to 
operation  the  effect  of  injections  of  bismuth  paste  (vaseline  20, 
paraffin  10,  lanoline  10,  subnitrate  of  bismuth  10)  may  be  tried. 
The  injections  are  made  twice  a  week  with  a  glass  syringe. 

2.  Spontaneous  Eenal  Fistula 

In  this  category  are  placed  a  small  group  of  fistulse  which  do 
not  follow  operation  on  the  kidney. 

Wounds  of  the  kidney  cause  a  urinary  fistula  only  when  the 
renal  pelvis  or  calyces  are  injured.  A  fistula  persists  for  some 
months  and  sometimes  for  years,  but  is  rarely  permanent  {see  under 
Wounds  of  the  Kidney,  p.  107).  An  untreated  pyonephrosis 
ruptures  into  the  perinephritic  tissue,  and  the  pus  either  finds  its 
way  to  the  surface  of  the  body  or  opens  into  the  pleural  cavity,  a 
bronchus,  the  stomach,  duodenum,  or  elsewhere,  giving  rise  to  a 
reno-cutaneous,  reno-pulmonary,  reno-intestinal,  or  reno-gastric 
fistula. 

The  discharge  is  purulent  or  uro-purulent.     There  may  be  con- 
siderable difficulty  in  diagnosis.     To  symptoms  of  pyonephrosis 
there    are    superadded  those  of    rupture  of  a 
large  abscess  into  a  bronchus  or  elsewhere. 

The  opening  of  the  fistula  is  usually  small, 
so  that  the  escape  of  pus  into  the  bronchus 
or  elsewhere  is  intermittent.  In  the  intervals 
there  is  retention  of  pus  in  the  kidney  or  around 
it,  causing  fever  and  recurrent  rigors. 

A   small   number   of   cases  have   been   re- 
corded in  which  calculi  have  been  discharged 
Fig.  31. — Gollec-     from    a    spontaneous   renal    fistula.     Fig.    31 
tion      of     calculi     shows  a  number  of    small    calculi    discharged 
ISC  argea    trom     fj-Qj^^  g^  spontaneous  sinus  in  a  man  aged  78. 
tula  of  kidney.       ^  small  abscess  formed  on  the  right  side,  1 J  in. 
below  the  iliac   crest  and  the  same  distance 
external  to  the  posterior  superior  iliac    spine ;  this    was  incised, 
and  the  sinus  persisted  and  discharged  small  calculi.     The  radio- 
gram (Plate  8,  Fig.   1)  shows  a  large  calculous  mass  in  the  right 
kidney  with  a  number  of  small    shadows  of  calculi  lying  in  the 
sinus.     There  was  a  history  of  litholapaxy  ten  years  previously, 


^/^ 

^m^^ 


Fig.  1. — Shadows  of  large  calculus  in  kidney  and 
number  of  small  calculi  (arrow)  lying  in 
spontaneously  formed  fistula.  A  number 
of  calculi  were  discharged  through  the 
fistula.     (Sec  p.   156  and  Fig.  31.) 

Fig.  2. — Hydronephrosis  due  to  adhesions  round 
vertebrae  in  scoliosis.  Arrows  point  to 
lateral  curvature  of  spine,  to  opaque 
catheter  in  ureter,  and  to  three  of  the 
dilated  calyces.     (P.   168.) 


Plate  8. 


XI]  RENAL   FISTULA  157 

and  of  bladder  symptoms,  but  no  renal  symptoms,  and  the  general 
health  was  unimpaired. 

3.  Postoperative  "Renal  Fistul/E 

These  fistulse  are  cutaneous  and  open  in  the  lumbar  region, 
generally  at  the  posterior  end  of  the  operation  sear.  There  is 
commonly  a  single  fistula ;  occasionally  two  or  more  exist,  and 
communicate  by  subcutaneous  tracks.  The  latter  are  most  fre- 
quently found  in  tuberculous  disease. 

The  orifice  of  the  fistula  is  often  retracted  and  hidden  in  folds 
of  skin.  If  placed  far  back  in  the  lumbar  region  it  is  more  likely 
to  be  on  the  level  of  the  surface.  It  is  narrow  and  the  edges  are 
smooth.  In  tuberculous  disease  and  in  some  septic  cases  there 
may  be  granulations  sprouting  from  the  fistula,  and  tags  of  scar 
tissue  around  it.  The  discharge  may  be  urine,  urine  mixed  with 
pus,  or  pus. 

The  track  of  the  fistula  is  narrow,  and  it  usually  passes  in  a 
straight  course  down  to  the  kidney.  The  walls  consist  of  thick, 
dense  fibrous  tissue. 

The  state  of  the  kidney  and  ureter  varies  according  to  the 
disease  for  which  the  operation  was  performed. 

The  factors  which  cause  a  temporary  fistula  to  persist  or 
become  permanent  are  various. 

The  fistula  may  give  exit  to  pus  or  urine,  which  would  accumu- 
late under  tension  if  it  closed.  Disease,  such  as  tuberculosis,  may 
spread  along  the  track,  or  concretions  form  in  the  lumen  and 
prevent  healing.  The  wall  of  the  fistula  may  become  so  thick, 
hard,  and  callous  from  prolonged  use  of  drainage  tubes,  or  from 
continued  discharge  of  urine  and  pus,  that  spontaneous  healing 
is  impossible. 

After  nephrolithotomy  there  is  seldom  a  fistula,  unless  urinary 
obstruction  is  present,  or  unless  there  are  infected  calculi  remaining 
in  the  kidney. 

Pyelotomy  for  stone  has  been  followed  by  a  fistula,  but  this 
is  rare,  unless  some  collateral  condition,  such  as  ureteritis  or  narrow- 
ing of  the  ureter,  exists,  or  unless  the  drainage  by  rubber  tubes  or 
other  means  is  unduly  prolonged. 

Nephrotomy  in  hydronephrosis  w^here  the  obstruction  has  not 
been  removed  is  followed  by  a  fistula  which  discharges  w^atery  urine. 
In  pyonephrosis  a  uropurulent  fistula  persists,  which  is  chiefly  due 
to  the  ureteral  obstruction,  but  partly  also  to  the  thick  fibrous 
w^alls  being  too  rigid  to  collapse. 

xA_fter  nephrectomy  a  fistula  may  persist  and  may  be  due  to 
necrotic  portions  of  the  kidney  or  renal   pelvis   forming  part  of 


158  THE   KIDNEY  [chap. 

the  stump  of  the  pedicle,  to  an  infected  Hgature  of  thick  silk  on 
the  pedicle,  to  infection  of  the  wound  from  a  septic  ureter,  or  to 
tuberculous  infection  of  the  wound.  In  these  conditions  a  purulent 
discharge  issues  from  the  fistula. 

After  nephrectomy  considerable  quantities  of  urine  may  be 
discharged  from  the  wound,  derived  from  fragments  of  kidney 
tissue  remaining  on  the  stump  of  the  pedicle.  These  portions  of 
kidney  tissue  lie  on  the  distal  side  of  the  ligature,  and  are  appar- 
ently cut  of?  from  their  blood  supply.  In  a  few  days  they  necrose 
and  the  secretion  of  urine  ceases.  A  permanent  fistula  discharging 
urine  may  be  caused  by  a  patent  dilated  ureter  allowing  the  urine 
of  the  remaining  kidney  to  ascend  from  the  bladder. 

Finally,  there  are  permanent  urinary  fistulse  made  by  nephros- 
tomy to  effect  drainage  in  a  ureter  blocked  by  irremediable  disease. 

Diagfnosis. — In  many  cases  the  cause  of  the  fistula  and  the 
condition  of  the  kidney  are  well  known,  but  in  others  it  is  uncer- 
tain whether  the  copious  purulent  secretion  contains  urine. 

The  discharge  should  be  examined  for  urea,  which  can  be 
detected  if  even  a  small  quantity  of  urine  is  present.  After  an 
intramuscular  injection  of  methylene  blue,  a  urinary  discharge 
will  be  tinged  with  blue. 

By  catheterization  of  the  ureters  or  separation  of  the  urines 
in  the  bladder,  it  is  found  either  that  the  fistula  drains  away  all 
the  urine  secreted  by  the  kidney,  or  that  it  drains  away  only  a 
part  of  it,  the  remaining  urine,  usually  a  small  quantity,  passing 
down  the  ureter. 

Catheterization  of  the  ureter  on  this  side  will  also  give  informa- 
tion in  regard  to  the  presence  of  stricture. 

Treatment. — In  some  cases  nephrostomy  has  been  performed 
with  the  view  of  producing  a  permanent  fistula.  In  such  cases 
the  treatment  consists  in  devising  an  apparatus  which  will  drain 
away  the  discharge  and  prevent  it  from  soaking  the  clothes.  A 
modification  of  Irving's  suprapubic  drainage  apparatus  is  the  best 
for  this  purpose  (Fig.  32). 

In  purulent  non-urinary  fistulse  it  will  be  sufiicient  to  dissect 
out  the  fistulous  track  and  expose  the  kidney  by  a  free  incision, 
opening  up  pockets  and  tracks  and  providing  free  drainage.  In- 
jection of  a  bismuth  paste  as  in  non-urinary  perirenal  fistulse  may 
be  tried  (p.  156). 

Before  undertaking  radical  treatment  in  urinary  fistulse  it  is 
necessary  to  know  (1)  if  the  ureter  is  patent,  (2)  the  functional 
power  of  the  fistulous  kidney  and  of  the  second  kidney.  This 
information  is  obtained  by  catheterization  of  the  ureter,  by  examin- 
ation of  the  discharge  from  the  fistula  and  that  from  the  ureter  of 


XI 


RENAI.  FISTULA 


150 


the  fistulous  kidney,  and  of  the  urine  from  the  ureter  of  the  second 
kidney,  and  by  usinf^  the  tests  for  the  renal  function. 

If  the  ureter  is  found  to  be  patent,  Albarran  recommends 
drainage  by  a  catheter  en  demeure  in  the  ureter.  In  order  to  get 
a  large  catheter  into  the  ureter,  he  introduces,  by  means  of  the 
cystoscope,  a  long  stilette  (70  cm.)  which  is  flexible  for  the  first 
6  cm.  Over  this  stilette  a  catheter  with  a  terminal  eye  is  passed 
and  ascends  the  ureter  to  the  renal  pelvis.  The  catheter  is  held 
in  place  and  the  stilette  removed  ;  the  catheter  is  left  in  the  ureter 
for  four  or  five  days  and  then  changed  after  passing  the  stilette 


l\    li     Outlet 


Fig.  32. — Watson's  apparatus  for  collecting  urine   in 
permanent  renal  fistula. 

as  a  guide.  Eventually  a  No.  13  Fr.  catheter  may  thus  be  passed. 
The  renal  pelvis  is  washed  daily  with  silver  nitrate  solution  (1  in 
1,000).  This  continuous  catheterization  is  maintained  for  three 
weeks  {see  also  under  Pyonephrosis,  p.  151).  Should  it  fail,  a  plastic 
operation  should  be  performed  upon  the  renal  pelvis. 

If  the  ureter  is  impassable  and  the  kidney  has  been  shown  to 
retain  a  considerable  part  of  its  function,  then  also  a  plastic  opera- 
tion on  the  renal  pelvis  will  be  necessary.  But  should  the  func- 
tional value  of  the  kidney  be  low,  and  that  of  the  second  kidney 
adequate,  nephrectomy  should  be  performed. 

LITERATURE 
Albarran,  XH''  fonf^res  franc,  de  Chir.,  Paris,  1898,  p.  So. 
Heitz-Boyer  vt  Moreno,   Ann.  d.  Mai.  d.  Org.  Gen.  Urin.,  1910,  Xo.  11, 
Pouquet,  These  de  Paris,   1901. 


IGO  THE   KIDNEY  [chap. 

SURGICAL    TREATMENT    OF    NON-SUPPURATIVE 
NEPHRITIS 

Acute  Nephritis 

In  1896,  Reginald  Harrison  suggested  operative  interference  in 
certain  cases  of  acute  nephritis.  He  operated  on  "  cases  of  scar- 
latinal nephritis,  nephritis  complicating  influenza,  traumatic  nephri- 
tis, and  nephritis  which  had  followed  a  chill."  The  operations  were 
undertaken  on  account  of  one  or  more  of  the  following  symptoms, 
viz.  diminished  secretion  of  urine,  pain,  haematuria.  He  recom- 
mended operation  in  cases  of  acute  nephritis  where  convalescence 
was  delayed,  and  albumin  and  casts  did  not  disappear  from  the 
urine ;  also  in  cases  such  as  the  malignant  type  of  scarlatinal 
nephritis  with  suppression,  and  lastly  where  cardiac  and  circulatory 
complications  were  present.  The  operation  was  performed  with 
the  object  of  setting  aside  the  dangerous  symptoms  and  also  of 
preventing  the  sequence  of  chronic  nephritis.  Harrison  suggested 
incision  of  the  renal  capsule  and  puncture  of  the  kidney  to  relieve 
the  renal  tension  in  these  cases.  Other  observers  (Pel  and  Rosen- 
stein)  recommended  nephrotomy  in  acute  nephritis  when  oliguria 
was  present  and  medical  treatment  had  failed.  Confusion  in  regard 
to  statistics  has  been  caused  by  the  publication  of  cases  of  suppura- 
tive nephritis  in  the  same  category  as  those  referred  to  above. 

All  Harrison's  cases  recovered,  but  the  after-history  is  unre- 
corded. 

Chronic  Bright' s  Disease 

Acute    exacerbations     in     chronic     Bright's     disease. — 

Edebohls,  Pousson,  Casper,  and  others  have  treated  the  acute 
exacerbations  of  chronic  Bright's  disease  by  operation.  In  these 
cases  surgical  interference  is  supplementary  to  medical  treatment. 
Where  there  are  symptoms  of  uraemia,  diminished  secretion  of 
urine,  and  oedema,  operation  may  be  of  service  when  medical  treat- 
ment has  failed.  Cases  with  advanced  cardio-vascular  changes 
and  pulmonary  complications  are  unsuitable  for  operation. 

Decapsulation  and  nephrotomy  are  the  operations  recommended. 
Except  in  the  rare  cases  when  the  disease  can  be  proved  to  be 
unilateral,  decapsulation  should  be  rapidly  performed  on  both 
sides.  Pousson  recommends  that  nephrotomy  be  performed  on 
one  side,  and  only  decapsulation  on  the  other. 

The  immediate  results  give  a  mortality  of  25  per  cent.  (Pousson), 
some  part  of  which  is  due  to  the  patient  being  moribund  when 
the  operation  is  performed.  Of  92  patients  Avho  survived  the 
operation,  8  were  considered  as  cured.     The  others  died  after  a 


XI]  CHRONIC  BRIGHPS  DISEASE  161 

temporary  relief  lasting  from  some  months  to  one  or  two  years 
in  a  few  cases. 

In  my  experience  of  decapsulation  and  nephrotomy  in  these 
cases  and  in  large  white  kidney  very  striking  improvement  may 
be  observed.  OEdema  and  ascites  disappear,  and  the  patient,  who 
has  been  rapidly  losing  ground  under  medicinal  treatment,  regains 
some  measure  of  health  and  vigour.  This  improvement  is,  how- 
ever, only  temporary,  and  after  some  weeks  or  months  relapse 
occurs  and  the  disease  pursues  its  course. 

Chronic  interstitial  nephritis  with  haematuria.  —  These 
cases  have  already  been  discussed  under  the  term  Essential  Haema- 
turia (p.   59). 

Chronic  nephritis  with  pain.— Legueu  described  these  cases 
as  neuralgia  of  the  kidney.  In  a  few  cases  the  renal  condition 
is  that  of  chronic  Bright' s  disease,  but  in  many  cases  there  has 
been  a  renal  calculus  at  some  previous  date,  while  in  others  there 
is  a  history  of  traumatism. 

The  kidney  shows  cJironic  nephritis,  and  there  are  thickening 
and  adhesion  of  the  fibrous  capsule  and  fibrosis  of  the  fatty  envelope. 
The  pain  may  be  localized  to  the  kidney,  and  be  spontaneous, 
constant,  and  unaffected  by  movement,  or  there  are  attacks  of 
renal  colic.  There  may  be  a  trace  of  albumin  with  hyaline  and 
granular  casts. 

Nephrectomy,  nephrotomy,  capsulotomy,  decapsulation,  and 
simple  freeing  of  the  kidney  from  surrounding  adhesions  have  been 
practised. 

The  operation,  like  that  for  haematuria  in  partial  nephritis, 
usually  takes  the  form  of  an  exploratory  nephrotomy,  and  to  this 
decapsulation  may  be  added. 

The  great  majority  of  patients  have  been  relieved  by  operation, 
and  the  relief  is  known  to  have  lasted  for  some  years.  If  there  have 
been  a  diminution  in  the  quantity  of  urine  and  albuminuria,  these 
symptoms  disappear. 

Decapsulation  in  chronic  Bright's  disease.  —  In  1899 
Edebohls  suggested  nephrotomy  as  a  method  of  treatment  of 
chronic  nephritis  in  cases  of  chronic  nephritis  in  movable  kidney. 
Newman,  of  Glasgow,  had  previously  treated  two  cases  of  this 
nature  by  nephropexy. 

In  1901  Edebohls  proposed  decapsulation  of  the  kidney  with 
the  object  of  curing  chronic  Bright' s  disease.  He  held  that  the 
thickened  fibrous  capsule  prevented  the  establishment  of  a  col- 
lateral circulation,  and  that  if  this  barrier  were  removed  a  free 
flow  of  blood  through  the  kidney,  which  the  diseased  vessels  were 
unable  to  supply,  was  provided  by  anastomosis  with  the  parietal 


162  THE   KIDNEY  [chap. 

vessels.  By  this  means  the  increased  interstitial  tissue  would  be 
absorbed,  pressure  on  the  tubules  removed,  and  a  regeneration  of 
renal  epithelium  take  place. 

Experimental  inquiry  into  this  hypothesis  has  shown  that  no 
damage  is  done  to  the  kidney  by  decapsulation,  and  that  although 
the  fibrous  capsule  invariably  re-forms  in  a  few  weeks  the  new 
capsule  is  composed  of  loose  connective  tissue  which  does  not 
compress  the  kidney.  A  parietal  anastomosis  has  actually  been 
observed,  which  was  not  strangled  by  contraction  of  the  new 
capsule.  On  the  other  hand.  Hall  and  Herxheimer  have  shown 
that  a  thick,  strong  connective  tissue  capsule  is  formed  in  from 
eight  to  fourteen  days,  and  they  did  not  find  anastomotic  vessels 
passing  through  the  new  capsule.  Conflicting  statements  have 
been  made  in  regard  to  the  results  found  post  mortem  after 
decapsulation  in  human  beings. 

The  kidney  has  also  been  transplanted  into  the  peritoneal 
cavity  and  formed  adhesions  with  the  serous  membrane  or  with 
the  omentum. 

Results. — Pousson  gives  a  mortality  of  5  per  cent.  Of  55  cases, 
36  survived  more  than  three  months  after  the  operation. 

Of  10  cases  of  nephritis  with  nephroptosis,  there  were  9  greatly 
improved,  3  of  which  were  said  to  be  cured;  while  of  16  cases 
of  nephritis  without  nephroptosis  3  were  improved,  4  much  im- 
proved, 4  greatly  improved,  and  5  cured.  The  5  cases  of  cure 
were  under  observation  for  11  years,  6|  years,  5|  years,  2  years, 
and  1  year. 

It  will  be  seen,  therefore,  that  although  the  course  of  the  disease 
is  uninfluenced  in  a  considerable  proportion  of  cases,  improvement 
is  undoubted  in  some,  and  it  is  claimed  that  a  cure  has  been 
brought  about  in  a  few  cases. 

The  cases  of  movable  kidney  with  albuminuria  and  tube  casts 
should  be  carefully  separated  from  the  others,  for  the  prognosis 
without  operation  is  very  diflerent  from  that  of  chronic  Bright's 
disease,  and  the  effect  of  nephropexy  alone  is  to  cure  most  of 
these  cases.  In  cases  of  chronic  Bright's  disease  the  results 
might  be  improved  by  operation  performed  at  an  earlier  date  than 
is  usual. 

LITERATURE 

Edebohls,  Med.  News,  April  22,  1899  ;    Med.  Bee,  May  4,  1901. 
Hall  and  Herxheimer,  Brit.  Med.  Journ.,  1904,  i.  821. 
Harrison,  Lancet,  1896,  p.  19. 
Legueu,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1891. 
Lehmann,  Berl.  klin.  Woch.,  Jan.,  1912,  p.  158, 
Newman,  Trans.  Clin.  Soc,  1897. 
■'  Pousson,   Chirurgie  des  Nephrites.     Paris,  1909. 

Walker,  Thomson,  Pract.,  June,  1903. 


XI]  PUERPERAL   ECLAMPSIA  163 

SURGICAL   TREATMENT   OF   PUERPERAL   ECLAMPSIA 

Although  the  modern  views  on  the  pathology  of  puerperal 
eclampsia  are  not  yet  settled,  it  is  undoubted  that  there  are  changes 
in  the  kidneys,  amounting  to  great  engorgement  or  even  to  acute 
nephritis,  and  symptoms  are  present  which  result  from  interference 
with  the  renal  function. 

On  these  grounds  decapsulation  of  the  kidneys  and  nephrotomy 
have  been  practised  in  this  fatal  malady,  with  the  object  of  relieving 
the  renal  engorgement  and  allowing  the  escape  of  poisons. 

In  some  cases  the  convulsions  cease  and  the  symptoms  dis- 
appear, the  secretion  of  urine  becoming  re-established.  Kehrer 
collected  26  cases  with  a  mortality  of  36  per  cent. 

The  general  opinion  is  not,  however,  favourable  to  decapsulation. 
The  state  of  the  kidneys,  de  Bovis  holds,  plays  but  a  secondary 
part  in  the  disease,  and  even  if  the  renal  function  is  resumed  it 
does  not  prevent  the  development  of  hepatic  necrosis,  or  the  pete- 
chial haemorrhages  of  the  encephalitis  found  in  eclampsia.  There 
may,  however,  he  believes,  be  cases  where  the  renal  lesions  exceed 
the  other  morbid  changes  in  the  body,  and  these  cases  explain 
certain  striking  successes  which  are  too  numerous  to  be  mere 
coincidence. 

LITERATURE 

De  Bovis,  Semaine  Med.,  Jan.,  1912,  p.  3. 

Kehrer,  Zeits.  /.  Gyn.  u.  Urol.,  1909,  ii.  HI.     "^       '         [i.  561. 

Pousson  et  Chambrelent,  ^?i?i.  d.  Mai.  d.  Org.  Gen.-Urin.,  1906, 


CHAPTER  XII 
HYDRONEPHROSIS 

Hydronephrosis  is  chronic  aseptic  retention  of  urine  in  the  kidney 
and  renal  pelvis  due  to  obstruction. 

Etiology. — Hydronephrosis  is  slightly  more  frequent  on  the 
right  side  and  in  the  female  sex.  It  is  frequently  bilateral  when 
the  obstruction  is  urethral^  and  occasionally  when  it  is  ureteral. 
Of  665  cases,  217  were  unilateral  and  448  bilateral  (Newman). 
The  obstruction  may  be  ureteral  or  urethral. 

1.  Ureteral  obstruction  may  be  caused  by — 

(a)  Changes  in  the  wall  of  the  ureter,  such  as  valves,  folds, 

strictures. 

(b)  Obstruction  of  the  lumen  by  calculi,   tumours,  foreign 

bodies,  clot. 

(cj  Pressure  from  without  by  tumours,  fibrous. bands,  puru- 
lent collections,  an  aberrant  renal  vessel. 

{d)  Kinking  of  the  ureter  due  to  undue  mobility  of  the  kidney. 

(e)  Torsion  of  the  ureter. 

2.  Urethral  obstruction  may  be  caused  by  a  congenital  fold 
or  diaphragm,  or  obliteration,  or  more  frequently  by  stricture  and 
enlarged  prostate. 

There  are  two  principal  categories  into  which  the  cases  of 
hydronephrosis  fall,  namely  : 

(1)  Congenital. 

(2)  Acquired. 

1.  By  congenital  hydronephrosis  is  understood  cases  of  hydro- 
nephrosis occurring  in  the  foetus  or  new-born,  or  appearing  soon 
after  birth.  Cases  of  hydronephrosis  occurring  in  adults  and 
ascribed  to  congenital  malformation  are  not  included  in  this  category. 

In  congenital  hydronephrosis  one  or  both  kidneys  may  be 
affected.  When  the  condition  is  unilateral  it  is  due  to  an  abnormal 
renal  artery,  to  valves  or  folds,  or  to  stenosis  of  the  orifice  of  the 
ureter,  or  bending  or  kinking  of  the  duct,  which  is  malplaced  in 
the  bladder,  urethra,  ejaculatory  duct,  seminal  vesicle,  vas  deferens, 
vagina,    or   urethro-vaginal   septum.     More   frequently   congenital 

164 


CHAP.  XII]  HYDRONEPHROSIS  165 

hydronephrosis  is  bilateral,  and  is  due  to  obstruction  in  the  urethra 
by  a  complete  or  an  incomplete  septum  or  imperforate  portion,  a 
cyst,  torsion  of  the  penis  (Morris),  or  phimosis.  In  some  cases 
no  obstruction  can  be  found,  but  the  bladder,  both  ureters  and 
kidneys  are  greatly  dilated. 

2.  There  are  two  classes  of  acquired  hydronephrosis  : 

i.  Hydronephrosis  due  to  obstruction  in  the  lower  urinary 
organs  or  to  disease  in  the  pelvic  organs.  These  cases  are  almost 
invariably  bilateral.  Those  due  to  disease  of  the  lower  urinary 
organs  occur  most  frequently  in  the  male,  and  are  due  to  urethral 
stricture  and  enlarged  prostate,  and  less  frequently  to  growths  of 
the  bladder. 

Those  due  to  disease  of  the  pelvic  organs  occur  more  often  in 
the  female,  and  are  caused  by  new  growths  of  the  uterus  and 
ovaries,  less  frequently  by  carcinoma  of  the  rectum  in  either  sex, 
or  carcinoma  of  the  prostate  in  the  male. 

In  this  group  of  cases  the  distension  of  the  kidneys  is  seldom 
great,  and  may  not  be  detected  clinically.  When  the  lower  urinary 
organs  are  diseased,  infection  is  frequently  superadded  and  pyo- 
nephrosis may  develop. 

ii.  Hydronephrosis  due  to  obstruction  of  the  ureter.  In  these 
cases  the  narrow  point  is  usually  situated  at  the  upper  end  of 
the  ureter,  at  the  junction  of  the  ureter  and  renal  pelvis;  less 
frequently  the  middle  or  lower  end  of  the  ureter  is  the  seat  of 
obstruction,  and  the  ureter  is  dilated. 

Pathology.  1.  Hydronephrosis  due  to  valves,  folds,  tor- 
sion, and  stenosis. — The  ureter  and  renal  pelvis  are  developed 
as  an  outgrowth  from  the  Wolffian  duct.  As  development  pro- 
ceeds the  new-formed  tube  rotates  around  the  Wolffian  duct,  and, 
its  lower  end  being  fixed,  becomes  twisted  upon  its  axis.  This 
twisting  is  said  to  be  the  cause  of  torsion  of  the  ureter,  which  has 
been  described  in  rare  cases.  In  the  foetus  the  ureter  has  a  very 
irregular  lumen,  some  parts  being  dilated  and  others  contracted. 
The  narrowing  is  due  to  folds  formed  either  by  the  mucosa  or  by 
the  mucosa  and  muscular  layers ;  these  are  most  common  at  the 
uretero-pelvic  junction,  at  the  vesical  end  of  the  ureter,  and  in  the 
middle  of  its  course.  These  folds  are  constant  in  the  foetus,  and 
occur  at  the  upper  end  of  the  ureter  in  20  per  cent,  of  new-born 
children  (Wolfler).  If  anything  interferes  with  the  normal  growth 
of  the  ureter,  these  valvules  persist,  and  are  the  cause  of  hydro- 
nephrosis at  a  later  date.  (Fig.  33.)  English  found  that  of  65 
ureteral  strictures,  3  occurred  in  the  middle,  34  at  the  upper,  and 
28  at  the  lower  end — a  distribution  which  corresponds  very  closely 
with  that  of  the  physiological  valves  in  the  foetus. 


166 


THE   KIDNEY 


[chap. 


Folds  or  valves  of  mucous  membrane  may  be  found  at  the 
uretero-pelvic  junction  in  hydronephrosis  developing  in  adult  life, 
and  may  have  a  congenital  origin  or  may  result  from  other  causes, 
such  as  stone  or  the  drag  of  adhesions  outside  the  pelvis  and  ureter. 

Acquired  stricture  of  the  ureter  may  be  caused  by  external 
injury,  operations  on  the  ureter  or  on  the  pelvic  organs,  lacera- 


Fig.  33. — Hydronephrosis  in  boy  of  7,  due  to  multiple  congenital 
strictures  of  the  ureter.     Nephro-ureterectomy  specimen. 

tion  from  the  passage  of  calculi,  or  irritation  from  the  presence 
of  calculi  or  from  chronic  ureteritis. 

2.  Hydronephrosis  due  to  bands  and  adhesions  outside 
the  ureter. — The  most  frequent  site  of  obstruction  is  in  the 
region  of  the  uretero-pelvic  junction.  The  bands  may  affect  only 
the  pelvis  and  ureter,  or  the  ureter,  or  there  may  be  adhesions 
between  these  structures  and  neighbouring  organs. 


XII]  HYDRONEPHROSIS  :   PATHOLOGY  167 

In  the  most  frequent  form  the  ureter  is  bound  down  for  the 
first  inch  or  two  of  its  course  by  fibrous  adhesions  to  the  surface 
of  the  distended  pelvis  (Fig.  34).  Occasionally  there  is  narrowing 
of  the  lumen  at  the  pelvo-ureteral  junction  (Fig.  35),  and  it  is 
possible  that  the  ureter  may  have  become  adherent  to  the  already 
distended  pelvis.     Usually,  however,  the  lumen  is  found  to  be  free 


Fig.  34. — Hydronephrosis  due  to  bands  of  adhesion  between 
ureter  and  renal  pelvis. 

after  dissecting  away  the  bands  whichTwere  j[evidently  the  cause 
of  the  obstruction.  The  ureter  is  less  often  afiected  alone,  but 
may  sometimes  show  distortion  from  adhesions. 

The  cause  of  these  adhesions  may  be  obscure,  as,  except  for  the 
distension  of  the  kidney  and  pelvis,  there  is  no  disease  of  that  organ 
or  of  neighbouring  structures.  In  a  few  cases  stone  is  present 
with  extensive  perinephritis  and  periureteritis. 


168  THE   KIDNEY  [chap. 

Disease  of  'neighbouring  organs  is  sometimes  present  and  is 
obviously  the  cause  of  the  adhesions.  In  one  case  an  early  hydro- 
nephrosis was  shown  by  pyelography  (Plate  8,  Fig.  2)  to  be  due  to 
adhesions  around  a  spinal  curvature.  In  another  case  the  descend- 
ing colon  was  adherent  to  the  surface  of  a  hydronephrosis  binding 
the  first  2  in.  of  the  ureter  down  to  the  sac  in  a  thick  hard  plaque 
the  size  of  the  palm  of  the  hand.  A  faecal  fistula,  lasting  a  week, 
followed  dissection  of  this  adhesion  and  nephrectomy. 


J' 


Fig.  35. — Hydronephrosis  (pelvic  type)  due  to  stenosis  of 
uretero-pelvic  junction. 

In  Other  cases  the  bands  apparently  originated  in  appendicitis 
and  perityphlitis  or  duodenal  ulcer,  or  followed  peritonitis. 

3.  Hydronephrosis  due  to  abnormal  blood-vessels.— The  ab- 
normal vessels  which  are  important  are  those  which  pass  to  the  lower 
pole  of  the  kidney.  Such  an  artery  may  be  derived  from  the  main 
renal  artery  or  from  the  aorta,  and  it  passes  in  front  of  or  behind 
the  ureter  in  the  proportion  of  3  to  1.  The  vessel  may  be  as  large 
as  the  radial  artery.  Mayo  found  that  anomalous  blood-vessels 
were  present  in  20  out  of  27  cases  of  hydronephrosis,  and  the 
obstruction  in  each  case  was  at  the  point  at  which  the  vessels 
crossed  the  ureter. 


XIl] 


HYDRONEPHROSIS :  PATHOLOGY 


169 


The  importance  of  aberrant  vessels  as  the  cause"  of  ob- 
struction has  been  disputed,  for  in  some  specimens  which  have 
been  described  the  dilatation  commences  above  or  below  the 
aberrant  vessel,  and  is  evidently  independent  of  it.  The  relation 
of  the  hydronephrosis  to  the  vessels  in  these  cases  is  said  to  be 
accidental.  There  are,  however,  cases  in  which  no  other  cause 
for  obstruction  is  present,  and  in  which  division  of  the  vessels 


Fig.  36.— Hydronephrosis  due  to  aberrant  renal  vessels. 

Operation  view  :  aneurysm  needle  under  normal  ureter. 

suffices  to  relieve  the  obstruction.  This  was  the  case  in  a  boy 
of  13,  in  whom  I  found  an  aberrant  artery  and  vein  the  size  of 
the  ulnar  vessels  crossing  in  front  of  the  uretero-pelvic  junction 
to  the  anterior  surface  of  the  lower  pole  of  the  left  kidney.  The 
obstruction  was  caused  not  so  much  by  the  vessels  as  by  the  fibrous 
tissue  around  them,  which  formed  a  strong,  flat  band.  (Fig.  36.) 
There  was  no  stenosis  or  other  cause  of  obstruction,  and  the  con- 
dition was  cured  by  section  of  the  vessels  and  fibrous  band. 

4.  Hydronephrosis  due  to  movable  kidney. — In  a  large 
number  of  cases  of  hydronephrosis  the  kidney  is  abnormally  movable. 
In   these   cases  the   hydronephrosis  is  intermittent.     The   hydro- 


170  THE   KIDNEY  [chap. 

nephrosis  has  been  said  to  be  caused  bv  the  undue  mobility  kinking 
a  ureter  which  has  become  rigid  from  periureteral  adhesions,  but 
it  is  also  held  that  the  undue  mobility  is  secondary  to  the  increased 
size  of  the  kidney,  hydronephrotic  from  some  other  cause.  The 
former  hypothesis  is  probably  the  correct  explanation  of  the  origin 
of  the  dilatation. 

4.  Traumatic  hydronephrosis. — Hydronephrosis  may  be 
found  a  few  days  after  an  injury  to  the  loin,  or  it  may  develop 
several  months  or  years  after  the  injury.  In  the  majority  of  the 
former  the  fluid  collects  around  the  kidney  (pseudo-hydronephrosis) 
and  not  in  the  pelvis.  Gardner  points  out  that  the  severe  pain 
caused  by  rapidly  distending  the  renal  pelvis  is  completely  absent 
in  these  cases.  In  a  few  cases  of  tense  hydronephrosis  found 
soon  after  an  injury  the  distension  of  the  kidney  has  preceded 
the  injury.  Late  traumatic  hydronephrosis  results  from  stricture 
caused  by  injury  to  the  ureter. 

5.  Hydronephrosis  due  to  calculus. — The  degree  of  obstruc- 
tion does  not  correspond  to  the  size  of  the  calculus.  A  very 
large  calculus  (7  in.  by  1  in.),  or  numerous  calculi  (sixteen),  may 
cause  no  dilatation,  while  a  small  solitary  stone  may  cause  a 
hydronephrosis. 

The  stone  may  be  situated  at  the  outlet  of  the  pelvis,  or  it  may 
lie  at  the  vesical  end  of  the  ureter  (Fig.  37).  At  the  upper  end  of 
the  ureter  the  calculus  is  often  wedge-shaped,  and  usually  fixed ; 
at  the  lower  end  it  is  frequently  round  or  oval,  and  freely  movable 
upwards.  Stenosis  of  the  ureter  on  the  vesical  side  of  the  stone 
usually  becomes  superadded  if  the  case  is  of  long  standing. 

6.  Relation  of  diuresis  to  hydronephrosis. — Diuresis  plays 
an  important  part  in  the  production  of  hydronephrosis.  There 
are  many  cases  of  congenital  valves  and  narrowings  of  the  ureter, 
of  pressure  of  aberrant  vessels,  or  of  strictures  following  injury, 
in  which  the  lumen  is  sufficient  for  the  escape  of  the  urine  under 
ordinary  conditions,  but  is  too  narrow  to  drain  a  sudden  diuresis. 
From  the  comparative  obstruction  thus  established  hydro- 
nephrosis begins  to  develop,  and  the  pressure  it  exerts  upon  the 
ureter  increases  the  obstruction.  It  is  only  thus  that  I  can  explain 
the  delay  in  the  development  of  hydronephrosis  until  adult  life, 
where  the  cause  is  evidently  congenital.  A  young  Canadian  con-ij 
suited  me  with  regard  to  recurrent  attacks  of  renal  pain  and 
enlargement  due  to  the  intermittent  blocking  of  a  congenitally 
narrowed  pelvic  outlet.  Early  in  life  he  learnt  that  he  could  not 
take  whisky  or  beer  without  inducing  an  attack. 

A  hydronephrosis  is  said  to  be  "closed"  when  the  obstruction 
is  complete,  and  "open"  when  urine  escapes. 


XIl] 


HYDRONEPHROSIS  :   PATHOLOGY 


171 


Sudden  complete  obstruction  such  as  is  caused  by  ligaturing 
the  ureter  produces  either  shrinking  and  atrophy  of  the  kidney 
or  hydronephrosis  in  about  an  equal  number  of  cases.  According 
to  Lindermann  the  accumulation  of  fluid  depends  upon  the  develop- 
ment of  a  compensatory  anastomosis  being  established  through 
capsular  vessels  as  the  intrapelvic  pressure  blocks  the  renal  vessels. 

The  obstruction  in  hydronephrosis  is  only  complete  at  inter- 


Fig.  37. — Hydronephrosis  (renal  type)  with  dilatation  of 
ureter  caused  by  smooth  oval  calculus.  Nephro- 
ureterectomy  specimen. 

vals.  Even  in  the  largest  hydronephrosis  the  obstruction  is  rarely 
complete.  A  small  amount  of  fluid  escapes,  but  a  slightly  larger 
quantity  is  secreted  and  the  kidney  is  slowly  distended.  The  ten- 
sion never  becomes  sufficient  to  arrest  the  renal  secretion.  Where 
a  very  large  hydronephrosis  becomes  completely  closed  atrophy 
does  not  take  place,  for  the  absorption  from  the  sac  is  very  slight. 
In  an  open  hydronephrosis  there  may  be  attacks  of  retention 
from  kinking  of  the  ureter,  an  excess  of  polyuria,  or  other  causes, 


172  THE   KIDNEY  [chap. 

and  the  hydronephrosis  is  "  intermittent."  In  the  intervals  the 
sac  which  disappears  clinically  is  partly  collapsed,  and  still  con- 
tains a  considerable  quantity  of  fluid.  When  the  attack  of  re- 
tention occurs  the  sac  again  becomes  tensely  filled  with  fluid. 
After  a  varying  period  the  outflow  is  re-established. 

Pathological  anatomy. — In  the  early  stage  of  hydronephro- 
sis there  is  a  slight  increase  in  the  capacity  of  the  renal  pelvis. 
The  normal  pelvis  is  said  by  Luys  to  hold  from  2  to  3  grm.  of 
fluid  (about  30-50  minims) ;  but  Bazy  regards  a  pelvis  as  normal 
that  contains  ten  times  this  amount  of  fluid.  According  to 
Legueu  a  capacity  of  from  30-40  grm.  (about  1-1^  oz.)  indicates 
the  first  stage  of  hydronephrosis. 

The  kidney  is  not  increased  in  size  at  this  stage,  but  the  pelvis 
is  sac-like  and  the  kidney  hollowed.  The  apices  of  the  pyramids 
are  flattened  and  the  calyces  dilated.  This  stage  is  frequently 
met  with  at  operations  upon  movable  kidney,  stone  in  the  ureter, 
and  in  aseptic  urethral  obstruction.  In  the  last  the  dilatation 
seldom  passes  beyond  this  stage. 

In  the  fully  developed  hydronephrosis  either  the  pelvis  ("  pelvic 
type")  or  the  kidney  ("renal  type")  may  form  the  greater  part 
of  the  sac,  and  even  in  advanced  cases  the  pelvis  and  kidney  are 
distinguishable. 

When  the  pelvis  is  chiefly  affected  the  subdivisions  and  branches 
of  the  normal  pelvis  have  completely  disappeared.  (Fig.  35.) 
There  is  a  large  single  chamber,  one  part  of  which  is  capped  by 
the  kidney.  The  kidney  itself  is  hollowed,  and,  if  viewed  from 
the  inside,  the  calyces  form  large  round  secondary  chambers. 
The  thickness  of  kidney  substance  is  reduced  to  half  an  inch  or 
less.  There  is  a  groove  between  the  kidney  and  the  dilated  pelvis. 
The  wall  of  the  pelvic  sac  may  be  as  thin  as  brown  paper,  and 
consists  of  fibrous  tissue,  the  muscular  elements  having  disappeared. 
The  lining  is  smooth,  opaque,  white. 

When  the  kidney  alone  is  distended  the  pelvis  is  small  and  hidden 
by  the  cyst,  and  may  contain  a  stone.  (Fig.  37.)  The  surface 
shows  rounded  bosses  corresponding  to  the  sacs  of  the  hydro- 
nephrosis. These  are  formed  by  the  atrophy  of  the  pyramids  and 
destruction  of  the  renal  cortex.  Between  them  are  septa  show- 
ing as  depressions  on  the  surface  and  formed  by  the  sclerosed 
columns  of  Bertini.  There  is  a  small  central  cavity  with  numerous 
rounded  chambers  leading  from  it,  often  communicating  laterally 
with  each  other.  In  the  pelvis,  or  at  the  junction  of  the  pelvis 
and  ureter,  will  be  found  the  narrowing,  valve,  kink,  calculus,  or 
other  cause  of  the  hydronephrosis  ;  occasionally  no  cause  for 
obstruction  can  be  discovered. 


XII]  HYDRONEPHROSIS  173 

If  the  obstruction  is  situated  at  the  lower  end  of  the  ureter 
this  tube  is  dilated  and  tortuous,  and  its  wall  is  thick  and  has 
lost  its  elasticity  and  contractile  power. 

There  may  be  very  little  perirenal  inflammation,  but  fre- 
qu?ntly  there  are  tough  adhesions  between  the  hydronephrosis 
and  its  surroundings. 

A  partial  hydronephrosis  may  be  formed  by  the  blocking  of 
one  segment  of  a  double  pelvis  or  the  malformation  of  a  calyx. 
Hydronephrosis  has  been  observed  in  a  horseshoe  kidney  ;  about 
a  dozen  cases  are  on  record.  Morley  describes  an  interesting 
case  operated  on  by  Wright  in  which  hydronephrosis  was  pro- 
duced in  one  part  of  a  horseshoe  kidney  by  a  papilloma  at  the 
uretero-pelvic  junction. 

In  rare  cases  of  extreme  distension  the  kidney  tissue  has 
entirely  disappeared  from  the  wall,  but  there  is  usually  a  con- 
siderable layer  of  renal  parenchyma,  which  shows  an  increase  in 
the  interstitial  connective  tissue,  with  scattered  areas  of  round- 
cell  infiltration.  The  tubules  are  distorted,  and  the  lining  cells 
partly  or  totally  destroyed.  The  glomeruli  are  crowded  together 
and  sclerosed.  The  walls  of  the  blood-vessels  are  considerably 
thickened. 

The  hydronephrosis  may  hold  from  1  or  2  oz.  to  as  much  as 
26  pints  of  urine  of  the  specific  gravity  of  1005-1010,  and  con- 
taining traces  of  urea,  phosphates,  and  chlorides.  Occasionally 
as  a  result  of  injury,  and  sometimes  spontaneously,  the  fluid 
becomes  mixed  with  blood,  and  the  cyst  is  transformed  into  a 
haematonephrosis. 

The  second  kidney  is  usually  normal  and  hypertrophied. 
Occasionally  chronic  inflammatory  changes  are  observed  in  it. 
The  secretion  of  this  organ  is  often  reflexly  depressed,  and  com- 
plete anuria,  may  supervene  during  a  crisis  of  retention  in  the 
hydronephrotic  sac. 

Symptoms. — There  are  two  clinical  stages  of  hydronephrosis, 
(1)  an  early  stage,  before  a  tumour  can  be  detected,  and  (2)  a  stage 
when  an  enlarged  kidney  is  found.  The  first  of  these  is  the  more 
important  therapeutically. 

1.  Early  stage. — When  the  enlargement  of  the  kidney  is  not 
recognizable  on  palpation  the  hydronephrosis  is  latent.  Thus,  in 
a  malignant  growth  of  the  prostate,  bladder,  or  uterus,  anuria  may 
suddenly  set  in  without  any  previous  warning,  and  the  kidneys 
are  found  dilated  ;  or  again,  in  urethral  obstruction  from  enlarged 
prostate,  or  in  a  movable  kidney,  or  in  obstruction  from  valves, 
adhesions,  aberrant  vessels,  etc.,  though  there  may  be  no  symptoms 
directly  pointing  to  dilatation  of  the  kidney,  yet  dilatation  is  taking 


174  THE   KIDNEY  [chap. 

place.  In  other  cases  symptoms  are  present  at  this  early  stage : 
they  are  pain  and  polyuria. 

The  pain  is  a  constant  dull  aching,  is  situated  at  the  costo- 
muscular  angle  over  the  lower  pole  of  the  kidney,  and  is  bilateral  or 
umlateral  according  to  the  cause.  In  movable  kidney  it  is  indistin- 
guishable from  the  pain  caused  by  constant  dragging  on  the  renal 
pedicle.    In  other  cases  there  are  recurrent  attacks  of  renal  colic. 

Polyuria  is  an  important  sign.  The  specific  graAdty  of  the 
urine  is  diminished  and  the  percentage  of  urea  and  salts  reduced. 
In  bilateral  obstruction  this  may  be  very  marked,  but  in  unilateral 
hydronephrosis  it  is  frequently  obscured  by  the  urine  from  the 
second  kidney.  The  polyuria  may,  however,  be  remarkable  in 
early  unilateral  hydronephrosis. 

2.  Late  stage. — In  the  late  stage  the  symptoms  are  tumour, 
pain,  and  changes  in  the  urine. 

The  tumour  is  situated  in  the  loin,  or  it  may  fill  a  large  part 
of  the  abdomen.  It  is  rounded  and  moves  with  respiration. 
If  it  is  moderate  in  size  the  sensation  of  ballottement  can  be 
obtained,  but  if  very  large  it  will  be  in  contact  with  the  anterior 
abdominal  wall  and  ballottement  will  be  lost.  Fluctuation  cannot 
be  obtained.  The  tumour  is  not  tender.  A  partly  tympanitic 
note  can  be  ehcited  in  front  of  the  tumour,  while  the  outer  and 
lateral  parts  are  dull  on  percussion.  The  collapsed  colon  can 
frequently  be  felt  passing  vertically  over  its  anterior  surface. 
Where  the  pelvis  is  greatly  dilated  a  vertical  groove  may  be  felt, 
and  even  seen,  between  this  and  the  enlarged  kidney. 

There  are  two  clinical  types  of  hydronephrosis : 

1.  Constant  hydronephrosis. 

2.  Intermittent  hydronephrosis. 

1.  In  constant  hydronephrosis  the  tumour  varies  little  in 
size,  the  urine  is  normal  in  quantity  or  may  be  reduced,  and, 
beyond  some  aching  pain,  there  are  no  symptoms.  The  hydro- 
nephrosis in  such  cases  is  "  closed." 

2.  In  intermittent  hydronephrosis  there  are  periods  during 
which  the  tumour  completely  or  almost  completely  disappears. 
From  time  to  time  there  are  attacks  of  retention,  during  which 
the  patient  has  severe  pain  in  the  kidney  and  sometimes  renal 
colic,  the  urine  diminishes  in  quantity  and  may  become  com- 
pletely suppressed,  the  tumour  can  be  felt  and  is  large,  tense,  and 
sometimes  tender.  After  some  hours  or  some  days  the  patient 
suddenly  passes  a  large  quantity  of  pale  urine,  the  pain  subsides, 
and  the  tumour  rapidly  vanishes.  These  attacks  may  follow 
some  unusual  exertion  or  the  drinking  of  some  diuretic  such  as 
tea,  whisky,  or  beer. 


XII]  HYDRONEPHROSIS  175 

Cystoscopy. — Where  the  obstruction  is  situated  at  some  part 
of  the  ureter  the  ureteric  orifice  is  unchanged.  In  the  early  stages 
of  hydronephrosis  when  polyuria  is  present,  contractions  of  the 
ureter  are  more  frequent  on  the  diseased  side.  In  advanced  cases 
when  a  small  quantity  of  urine  escapes  there  is  a  slower  and  less 
frequent  contraction  of  the  orifice  on  the  diseased  side.  When 
the  obstruction  is  complete,  but  some  muscular  power  is  retained 
by  the  renal  pelvis  and  ureter,  an  occasional  gaping  movement  of 
the  orifice  is  seen  at  long  intervals,  although  no  efflux  takes  place. 
When  the  kidney  and  the  muscular  structure  of  the  pelvis  are 
completely  destroyed  the  orifice  is  still,  and  there  is  no  efflux. 
The  injection  of  methylene  blue  or  indigo  carmine  will  assist 
in  the  observation  of  the  efflux. 

Catheterization  of  the  ureters. — The  catheter  is  arrested 
at  some  part  of  the  ureter,  but  usually  it  will  move  on  after 
gentle  manipulation,  and  the  urine  passes  in  hurried  drips,  or  it 
may  spout  from  the  catheter  in  a  continuous  stream.  Pressure 
upon  the  hydronephrosis  increases  the  stream.  I  have  with- 
drawn 16  oz.  from  a  tense  hydronephrotic  sac  in  this  way.  The 
quantity  of  urine  which  drains  from  the  ureter  of  the  diseased 
side  is  greater  than  that  from  the  healthy  side  when  polyuria  is 
present.  I  have  observed  a  secretion  of  82-6  c.c.  on  the  diseased 
side  to  68-4  c.c.  on  the  healthy  side.  In  advanced  cases  a  small 
quantity  of  urine  is  collected  by  the  catheter  from  the  diseased  side. 
In  one  of  my  cases  45  c.c.  passed  from  the  dilated  kidney  and 
213  c.c.  from  the  healthy  kidney.  Finally,  no  urine  at  all  may  pass. 
In  one  case  I  observed  158-5  c.c.  with  1-3  per  cent,  of  urea,  and  in 
another  150  c.c.  of  urine  with  2  per  cent,  of  urea,  from  the  healthy 
kidney,  while  no  urine  appeared  on  the  diseased  side.  In  an  open 
hydronephrosis  the  eHmination  of  methylene  blue  is  delayed, 
diminished,  and  prolonged  on  the  diseased  side,  and  the  glycosuria 
produced  by  phloridzin  is  reduced  or  suppressed. 

After  relief  of  the  obstruction  by  operation  the  functional 
value  of  the  kidney  greatly  increases,  even  when  the  outflow  has 
been  completely  blocked. 

Diagnosis. — Diagnosis  in  the  early  stage  before  the  develop- 
ment of  a  tumour  is  important  therapeutically.  The  symptoms 
may  sometimes  lead  to  a  diagnosis.  Occasionally,  when  a  stone 
is  situated  at  the  lower  end  of  the  ureter,  the  X-rays  will  show 
the  outline  of  a  thickened  dilated  ureter  and  an  enlarged  kidney. 

Recently  other  methods  have  been  introduced  for  the  early 
diagnosis  of  hydronephrosis  : 

1.  Estimation  of  the  capacity  of  the  renal  pelvis. — This 
is  carried  out  by  the  passage  of  a  ureteral  catheter  into  the  renal 


176  THE   KIDNEY  [chap. 

pelvis.  The  urine  is  withdrawn  and  warm  boric  solution  is  slowly 
injected  from  a  graduated  syringe  until  pain  is  felt.  The 
quantity  of  fluid  injected  shows  the  capacity  of  the  pelvis ;  A 
capacity  of  30  to  40  c.c.  shows  a  slight  degree  of  hydronephrosis. 
This  method  is  open  to  some  objections.  It  may  be  uncertain 
whether  the  fluid  has  reached  the  pelvis  of  the  kidney,  and  some 
of  it  may  flow  back  into  the  bladder  alongside  the  catheter. 
If  the  fluid  is  coloured  with  methylene  blue,  the  latter  objection 
may  be  obviated.  If  more  than  150  c.c.  can  be  injected  without 
pain,  but  little  secreting  substance  remains  (Braasch).  There  is 
frequently  polyuria  of  the  diseased  kidney,  so  that  the  pelvis  will 
be  partly  filled  with  urine,  and  the  capacity  is  then  under- 
estimated. 

2.  Injection  of  metallic  solutions  and  photography  by 
the  X-rays  (pyelography). — Volcker  and  Lichtenberg  introduced 
this  method.  After  passing  a  ureteral  catheter  to  the  pelvis  of 
the  kidney  and  allowing  any  accumulated  fluid  to  run  off,  a  warm 
solution  of  collargol  (10  per  cent.)  is  slowly  injected  with  a  syringe, 
A  radiogram  is  now  taken,  and  shows  a  shadow  of  the  renal  pelAds. 
If  dilatation  is  present  it  is  demonstrated  by  the  shape  and  increased 
area  of  the  shadow.  (Plate  2,  Fig.  3;  Plate  3;  Plate  4,  Fig.  1.) 
There  is  usually  pain  in  the  renal  pelvis,  which  may  amount  to  renal 
colic.  The  fluid  is  aspirated  off  after  examination,  and  the  pelvis 
may  be  washed  with  warm  boric  solution.  Volcker  and  Lichten- 
berg employed  this  method  in  17  cases  without  harm  resulting. 
They  obtained  9  good  shadows,  4  that  were  less  defined,  and  4 
were  failures.  I  have  used  this  method  in  a  large  number  of 
cases,  and  have  found  no  difficulty  in  obtaining  a  clear  outline 
of  the  pelvis  and  calyces.  A  catheter  opaque  to  the  X-rays,  or  one 
opaque  in  alternate  half-inches,  should  be  used.  The  fluid  should 
not  be  injected,  but  is  allowed  to  run  in  by  hydrostatic  pressure 
from  a  glass  receptacle  attached  to  the  end  of  the  ureteric  catheter 
and  held  about  6  or  8  in.  above  the  external  meatus.  The  utmost 
gentleness  should  be  used,  and  forced  injection  must  be  avoided. 
The  injection  is  stopped  whenever  pelvic  pain  is  felt.  No  morphia 
or  other  anaesthetic  is  used  before  or  during  the  examination.  The 
abnormalities  that  can  be  shown  are  kinking  at  the  uretero-pelvic 
junction,  dilatation  of  one  or  more  calyces,  hydronephrosis  of  pelvic 
or  of  renal  type.  Where  an  abdominal  tumour  is  suspected  to 
be  a  hydronephrosis,  pyelography  will  demonstrate  the  position 
of  the  renal  pelvis  and  its  relation  to  the  tumour. 

3.  I  have  recently  introduced  two  methods  of  measurement 
of  the  X-ray  shadow  thrown  by  the  kidney  (Plate  9,  Figs.  1  and  2), 
as  follows  : — 


Fig.   1. — Author's    method    of    determining   normal   extent    of   renal 

areas  on  radiographic  plate.     (P.    176.) 
Fig.  2. — Method  of  measuring  shadow  of  kidney.     AAA,  opaque 

4-in.  segments  of  catheter  ;  B,  points  in  outline  of  kidney  ; 

C,     ^-in.    shadow    values    placed    across    kidney    shadow. 

(P.   176.) 
Fig.  3. — Shadows     thrown    by    metastatic    deposit    in    mediastinal 

glands    and    in    lungs     in    case    of    malignant     growth     of 

kidney.     (P.   199.; 

Plate  9. 


XII]  HYDRONEPHROSIS  177 

(a)  The  narrowest  transverse  measurement  of  the  body  of  the 
1st  lumbar  vertebra  is  doubled  and  projected  transversely  from 
the  middle  of  the  outer  edge  of  the  vertebral  body  and  a  point 
is  found.  The  same  measurements  are  made  in  regard  to  the 
2nd  and  3rd  lumbar  vertebrae.  By  joining  the  three  points  the 
normal  outer  border  of  the  kidney  is  roughly  indicated. 

(6)  A  ureteric  catheter  alternately  opaque  and  translucent  in 
segments  of  half  an  inch  is  passed  up  the  ureter.  On  the  plate 
the  shadow  value  of  half  an  inch  is  obtained,  and  by  using  this 
the  shadow  of  the  kidney  can  be  measured. 

Diseases  that  have  been  mistaken  for  hydronephrosis  are 
appendicitis  and  gall-stones.  The  diagnosis  depends  upon  the 
position  of  the  pain  and  tenderness,  the  absence  of  fever  and  of 
jaundice,  and  the  changes  in  the  urine.  If  a  tumour  is  present 
it  has  the  characters  of  renal  tumour.     {See  also  p.  35.) 

Course  and  prognosis. — These  depend  upon  the  cause.  In 
urethral  or  vesical  obstruction  sepsis  is  frequently  superadded, 
and  the  prognosis  becomes  very  grave.  In  ureteric  obstruc- 
tion infection  is  less  frequent  and  later.  It  may  take  place  by 
the  blood-stream,  and  a  pyo-hydronephrosis  is  formed.  Rupture 
of  the  sac  spontaneously  or  from  an  injury  is  very  rare.  Car- 
stair  and  Muir  -describe  a  fatal  case  of  rupture  of  a  hydronephrotic 
kidney  followed  by  suppression.  The  second  kidney  was  also 
hydronephrotic.  Where  the  second  kidney  is  hydronephrotic  or 
otherwise  diseased  the  ultimate  prognosis  is  grave,  suppression 
of  urine  eventually  taking  place. 

Treatment.  1.  Congenital  hydronephrosis.  —  Congenital 
hydronephrosis  is  more  frequently  of  interest  to  the  obstetrician 
than  to  the  surgeon,  on  account  of  the  difficulty  in  parturition  to 
which  it  may  give  rise. 

The  condition  is  frequently  associated  with  other  congenital 
malformations,  such  as  hare-lip,  imperforate  anus,  etc.,  and  the 
child  seldom  survives  birth  for  more  than  a  few  hours,  but  occa- 
sionally lives  a  few  months  and  very  rarely  four  or  five  years. 
Morris  performed  bilateral  nephrostomy  on  a  male  child  within 
twenty-foiu:  hours  of  its  birth,  and  the  child  survived  ninety- 
four  days. 

2.  Hydronephrosis  due  to  urethral,  vesical,  or  pelvic 
obstruction. — In  cases  of  urethral  obstruction  from  stricture 
or  enlarged  prostate  operations  will  be  undertaken  for  the  relief 
of  the  obstruction.  The  presence  of  dilatation  of  the  kidneys  in 
these  cases  and  in  cases  of  growths  of  the  pelvic  organs,  such 
as  uterine  and  ovarian  tumours,  increases  the  gravity  of  such 
operations.     In  growths  of  the  bladder  which  involve  one  ureter 

M 


178  THE   KIDNEY  [chap. 

causing  a  moderate  degree  of  hydronephrosis,  but  wliich  are  in 
other  respects  suitable  for  operation,  removal  of  the  growths  with 
transplantation  of  the  ureter  to  some  part  of  the  bladder  should 
be  undertaken.  No  direct  operative  treatment  of  the  hydro- 
nephrosis will  be  necessary  in  these  cases. 

In  nearly  all  these  cases  the  formation  of  a  hydronephrosis 
can  be  prevented  by  early  operation,  and  this  is  especially  true 
of  cases  of  urethral  obstruction  and  of  bladder  growth, 

3.  Movable  kidney  with  hydronephrosis. — In  cases  where 
hydronephrosis  is  combined  with  undue  mobility  of  the  kidney 
the  mobility  is  not  always,  at  the  time  of  the  operation,  the  cause 
of  the  obstruction.  Strictures,  valves,  and  adhesions  may  be 
found,  the  removal  of  which  is  necessary  for  the  relief  of  the 
obstruction.  But  in  many  instances  the  mobility  is  the  direct 
cause  of  the  ureteric  obstruction.  In  cases  of  movable  kidney 
hollowing  of  the  organ  with  slight  distension  of  the  pelvis  is  fre- 
quently discovered.  In  these  cases  nephropexy  will  be  suflicient 
to  cure  the  hydronephrosis. 

The  early  diagnosis  of  these  cases  is  possible  by  the  methods 
described,  and  early  operation  should  be  insisted  upon  in  order 
to  prevent  destruction  of  the  kidney  tissue. 

In  more  advanced  cases,  even  when  no  sign  of  narrowing  or 
adhesion  or  permanent  kinking  is  found  on  exposure  of  the  kidney, 
the  renal  pelvis  must  be  opened  and  the  patency  of  the  outlet 
and  the  ureter  examined.  When  a  plastic  operation  has  been 
found  necessary  in  such  cases,  nephropexy  must  also  be  performed. 

4.  Hydronephrosis  with  calculus. — ^When  calculus  in  the 
ureter  or  renal  pelvis  is  combined  with  hydronephrosis  the  dis- 
tension of  the  kidney  has  frequently  arisen  from  this  cause,  but 

n  some  cases  strictures  of  the  ureter  are  present,  and  have  either 
preceded  the  formation  of  calculus  or  have  developed  secondarily. 
In  addition  to  the  removal  of  the  calculus,  the  ureter  must  there- 
fore be  examined  for  the  presence  of  stricture. 

5.  Hydronephrosis  with  aberrant  vessels. — In  cases  where 
an  aberrant  vessel  is  found,  which  bears  no  close  relation  to  the 
point  of  obstruction,  it  need  only  be  divided  if  it  interferes  with 
the  plastic  operation  for  the  relief  of  the  obstruction. 

In  other  cases  it  lies  in  close  relation  to  the  point  of  obstruc- 
tion and  is  evidently  the  cause  of  the  obstruction.  If  it  is  an 
unimportant  vessel  passing  to  the  hilum  or  to  the  perirenal  tissues, 
or  an  additional  vessel  arising  from  the  aorta,  it  should  be  divided 
between  two  ligatures  and  the  patency  of  the  ureter  then  exam- 
ined, and  if  necessary  a  plastic  operation  performed.  If,  how- 
ever, the  aberrant  vessel  is  an  important  artery  passing  to  the 


XIl] 


HYDRONEPHROSIS :  TREATMENT 


179 


lower  pole  of  the  kidney,  and  it  is  not  proposed  to  perform  nephrec- 
tomy, the  vessel  should  be  preserved  and  some  form  of  plastic 
operation  carried  out  which  will  circumvent  the  obstruction  caused 
by  it.  Helferich  divided  such  a  vessel  between  ligatures,  and 
necrosis  of  a  part  of  the  kidney  followed,  necessitating  nephrec- 
tomy. 

In  a  case  in  which  I  divided  an  aberrant  artery  and  vein  of 
considerable  size  the  lower  pole  of  the  kidney  at  once  became 
blanched.  Before  the  end  of  the  operation,  however,  it  had 
become  dark  purple  from  the  establishment  of  collateral  blood 
supply.     No  ill  effects  followed. 

Operations  for  congenital  and  acquired  malformations 
of  the  ureter  and  renal  pelvis.  1.  Operations  which 
modify  the  form  of  the 
renal  pelvis. — i.  Nephro- 
fexy  in  intermittent  hydro- 
nephrosis. The  kidney  is  not 
only  raised  and  fixed,  but 
the  pelvis  resumes  its  old 
form,  provided  that  the 
distension  has  not  been  so 
long  established  as  to  lead 
to  a  weakening  and  sagging 
of  the  sac  wall. 

ii.  To  remove  the  pouch- 
ing Israel  introduced  an 
operation,  pyeloplication,  by 
which  the  redundant  part 
of  the  wall  is  folded  inwards 
after  emptying  the  sac  by 
puncture.  A  row  of  Lem- 
bert  sutures  fixes  the  fold. 
(Fig.  38.)  In  addition,  an  operation  may  be  performed  to  correct 
any  malformations  of  the  uretero-pelvic  junction. 

iii.  My  own  plan  is  to  resect  a  large  triangular  portion  of  the 
posterior  wall  of  the  renal  pelvis,  the  apex  of  the  triangle  being  at 
the  uretero-pelvic  junction  and  the  base  at  the  margin  of  the 
kidney.  A  plastic  operation  for  rehef  of  any  malformation  of 
the  uretero-pelvic  junction  is  then  performed,  and  the  wound 
closed  by  Lembert's  sutures.  A  flap  of  renal  capsule  is  reflected 
and  stitched  over  the  pelvic  wound,  the  kidney  drained  through 
a  nephrotomy  wound  and  fixed  to  the  posterior  abdominal  wall. 
(Fig.  39.) 

iv.  ''^  Ortho'pcBdic     resection''''     or      "  cafitonnage.'''' — Albarran 


Fig.  38.  —  Pyeloplication  ( Israel's 
operation)  in  pelvic  type  of  hydro- 
nephrosis. 


180 


THE   KIDNEY 


[chap. 


removes  the  pouch  consisting  of  the  portion  of  the  pelvis  and 
kidney  which  lies  below  the  level  of  the  outlet  of  the  pelvis, 
and  sutures  the  opening.     (Fig.  40.) 


Fig.  39. — Resection  of  the  renal  pelvis  (author's  operation) 
in  pelvic  type  of  hydronephrosis. 

a,  Triangular  flap  of  posterior  wall  of  pelvis  turned  down,  b.  Triangular  flap  removed,  closing 
wound  in  pelvis  ;  area  of  decapsulation  marked  with  dotted  line,  c,  Pelvic  wound  covered  with 
flap  of  capsule  and  fatty  tissue  ;  tubes  draining  kidney  and  in  ureter  through  nephrotomy  wound. 

2.  Anastomosis,     i.  Uretero-ureteral    anastomosis. — This    may 
be — 

[a)  End-to-end  anastomosis  with  transverse  or  oblique  section 


Fig.  40. — Orthopaedic  resection  (Albarran's  operation)  in 
hydronephrosis. 

^,  Portion  of  pelvis  and  kidney  below  dotted  line  to  be  resected.     ''',  Closing  wound  in 
pelvis  and  kidney. 

of  the  ends,  or  by  invagination  of  the  upper  into  the  lower  end 
(Pozzi).     (Fig.  41.) 

(6)  End-to-side   anastomosis   by   ligaturing   one   cut   end   and 


XIlJ 


HYDRONEPHROSIS :    TREATMENT 


181 


implanting  the   other   end   in   a   lateral   slit  below  the   ligature. 
(Fig.  4lA.) 

(c)  Lateral   anastomosis   without   section    or   after   section   of 


Fig.   41. — End-to-end 
anastomosis  of  ureter. 

Ends  cut  obliquely. 


Fig.  41a. — End-to-side  anasto- 
mosis of  ureter. 

'■,  Two  primary  sutures  in  position  ;  ''s   primary 
and  secondary  sutures  tied. 


the    ureter.      The    edges    of    two    lateral    incisions    are    brought 
together  by  interrupted  sutures.     (Fig.  42.) 

ii.  Pyelo-ureteral  anastomosis. — (a)  Lateral  anastomosis.  This 
is  the  oldest  plastic  operation  for  hydronephrosis,  and  was  per- 
formed by  Trendelenburg  in  1886. 
The  ureter  is  spht  longitudinally 
on  a  level  with  the  lowest  part 
of  the  hydronephrotic  sac,  and  a 
transverse  incision  is  made  in 
the  sac  wall.  The  edges  of  these 
wounds  are  sutured,  and  the 
kidney  is  then  drained  and  fixed. 
(Fig.  43.) 

(6)  Transplantation  of  the 
ureter  into  the  lowest  part  of 
the  sac  (uretero-pyelo-neostomy). 
The  ureter  is  cut  across  trans- 
versely or  obliquely,  and  in  addi- 
tion it  may  be  split  longitudinally 
to  prevent  stenosis.  An  incision 
is  made  into  the  lowest  part  of  the  sac,  a  small  triangular  por- 
tion excised,  and  the  ureteral  mucous  membrane  is  sutured  to  a 
pelvic  mucous  membrane.     (Fig.  44.) 

(c)  Nephro-cysto-anastomosis.  This  is  the  direct  anastomosis 
of  a  hydronephrotic  sac  with  the  bladder,  and  has  been  done  in 
cases  of  displaced  hydronephrotic  solitary  kidney.     The  operation 


Fig.  42. — Lateral  anastomosis 
of  ureter. 

1,  One  half  of  outer  continuous  suture  in 

position;  /',  one  half  of  inner   continuous 

suture  in  position. 


182 


THE   KIDNEY 


[chap. 


Fig.  43. — Lateral  pyelo-ureteral  anasto- 
mosis, showing  incisions  and  details 
of  stitching. 


is  performed  intraperitoneally.     The  sac  is  emptied  by  puncture, 
and  the  peritoneum   over   its   lowest   part   incised   and   brought 

into  contact  with  an 
incision  in  the  upper 
posterior  peritoneal 
surface  of  the  bladder, 
and  the  edges  sutured, 
iii.  Plastic  opera- 
tions on  strictures  and 
valves. — -{a)  Incision  of 
a  valve.  This  is  per- 
formed through  a  ne- 
phrotomy wound  or  a 
large  opening  in  the 
posterior  wall  of  the 
dilated  sac.  The  py- 
elo-ureteral opening  is 
found,  and  one  blade 
of  a  pair  of  scissors  introduced  into^^it.  The  valve  is  then  cut 
downwards.  If  it  is  thin  and  formed  only  of  mucous  membrane, 
this  will  sufl&ce ;  usually,  however,  the  thickness  of  the  pelvic 
and  ureteral  walls  is  cut  through,  and  these  are  sutured  to  each 
other.     (Fig.  45.) 

(6)  Uretero-pyeloplasty.  This  consists  in  making  a  longitu- 
dinal incision  through  a 
stricture  at  the  uretero- 
p  el  vie  junction  and  uniting 
the  edges  of  the  wound 
transversely.  It  is  similar 
to  the  operation  of  pyloro- 
plasty for  narrowing  of  the 
pylorus.  The  operation  is 
frequently  combined  with 
one  of  the  methods  of  re- 
ducing the  sac  of  the  hydro- 
nephrosis. 

General    observations. 
— 1.  These    operations    are 
performed    on     aseptic     or 
on  mildly  infected  hydronephrotic  sacs. 

2.  When  infection  is  present  a  preliminary  nephrotomy  with 
drainage  for  some  weeks  should  be  carried  out. 

3.  The    lumbar   extraperitoneal    route    is  used   in  all   except 
nephrocystostomy. 


Fig.  44. — Uretero-pyelo-neostomy, 
showing  details  of  stitching. 


XIl] 


HYDRONEPHROSIS  :  TREATMENT 


183 


4.  Adhesions  of  the  hydronephrotic  sac  and  ureter  should  be 
removed  before  commencing  the  plastic  operation. 

5.  Operations  on  the  renal  pelvis  are  performed  on  the  posterior 
surface.  The  renal  vessels  are  usually  adherent  to  and  stretched 
over  the  anterior  surface. 

6.  Before  commencing  the  operation  a  catheter  should  be  passed 
up  the  ureter  from  the  bladder  to  ascertain  the  position  of  the 
obstruction  and  assist  in  the  operative  measures. 

7.  The  pelvic  outlet  may  be  examined  through  a  nephrotomy 
or  pyelotomy  wound,  and  the  examination  is  rendered  simpler  by 

everting  this  part  of  the  sac  through  the  wound. 
\\  v^  8.  The    sac    should   be  drained   through  a  ne- 

/K\  \\V  phrotomy  wound.     Some  surgeons  leave  a  ureteric 


Fig.  45, — Plastic  operation  on  a  valve. 

rt,   Section  of  spur  consisting  of  pelvic  and  ureteral  walls,     b.  Stitching  cut  edges  of  pelvis  and 
ureter,    c,  Stitching  completed- 

catheter  in  situ,  but  this  is  not  necessary,  and  may  be  a  source 
of  irritation. 

9.  Nephropexy  is  an  important  part  of  many  of  these  operations. 

10.  Catgut  should  be  used  as  suture  material. 

Functional  value  of  a  hydronephrotic  kidney. — In  the 
early  stages  of  hydronephrosis  the  functional  power  of  the  kidney 
is  impaired,  but  if  the  obstruction  is  relieved  the  organ  will  secrete 
urine  almost  as  well  as  the  normal  kidney.  The  early  diagnosis 
and  operative  treatment  of  hydronephrosis  are  therefore  of  ex- 
treme importance.  In  the  fully  developed  hydronephrosis,  where 
the  layer  of  kidney  tissue  is  reduced  to  half  an  inch,  the  organ 
still  retains  a  considerable  degree  of  functional  power.  I  have 
operated  on  both  kidneys  for  the  relief  of  obstruction  in  bilateral 
advanced  hydronephrosis,  and  the  patient  was  well  two  and  a 
half  years  later.  There  are  cases  of  bilateral  advanced  hydro- 
nephrosis in  which  the  patient  has  lived  for  many  years,  and 
there  are   other  cases  where  a  solitary  kidney  was  converted  into 


184 


THE   KIDNEY 


[chap. 


Operations 

Deaths 

Faihires 

. .     12 

-, 
i. 

3 

..18 

1 

4 

..19 

2 

6 

..13 

r.1 

2 

3 

al 

..     1 

..4 

..8 

— 

1 

1 



.      11 

.     — 

— 

.     86 

I 

17 

a  hydronephrotic  sac  and  yet  carried  on  a  function  sufficient  to 
maintain  life.  In  the  hydronephrotic  sac  the  renal  tissue,  although 
greatly  damaged,  persists  even  when  the  wail  is  only  a  few  milli- 
metres thick,  and  it  very  rarely  completely  disappears.  After  relief 
of  the  obstruction  the  kidney  does  not  return  to  the  normal  state, 
and  if  regeneration  takes  place  it  is  not  the  invariable  rule. 

Results  of  plastic  operations. — Schloffer  collected  86  opera- 
tions with  the  following  results  : — 

Section  o£  valves 
Uretero-pyeloplasty  . . 
Uretero-pyeloneostomy 
Lateral  anastomosis 
Plastic    operations    on 

pelvis 
Pyeloplication 
Orthopaedic  resection 
Combined  operations 

!  Total    .. 

To  this  I  can  add  three  personal  cases  treated  by  my  method, 
with  two  successes,  and  one  failure  due  to  haemorrhage  into  the 
resected  pelvis.  This  patient  was  submitted  to  nephrectomy  and 
recovered.  I  can  also  record  a  successful  result  in  a  case  of  pyelo- 
ureteral  anastomosis.  In  a  fourth  case  there  was  bilateral  hydro- 
nephrosis, and  the  operation  was  performed  on  each  pelvis  with 
an  interval  of  three  weeks.  The  patient  died,  two  months  later 
of  renal  failure,  which  had  commenced  some  months  previously 
and  slowly  progressed. 

Nephrostomy. — Incision  and  drainage  of  the  sac  without 
any  attempt  to  overcome  the  cause  of  the  obstruction  is  some- 
times performed.  This  has  been  followed  in  between  30  to  45 
per  cent,  of  cases  by  re-establishment  of  the  flow  of  the  urine 
through  the  ureter  and  healing  of  the  nephrotomy  wound.  In 
the  remaining  cases  a  fistula  persists. 

Nephrectomy. — Primary  nephrectomy  is  only  indicated  when 
the  sac  is  very  large  and  its  wall  so  thin  and  fibrous  that  no  renal 
tissue  is  present,  and  only  in  cases  when  it  can  be  proved  that  a 
second  kidney  is  present  and  efiicient. 

Secondary  nephrectomy  is  required  when  nephrotomy  and 
plastic  operations  have  failed. 

LITERATUEE 

Albarran,  Bull,  de  VAcad.  de  Med.,  1898,  p.  59. 

Albarran  and  Legueu,  Congres  frang.  de  Chir.,  1892,  p.  561. 

Braasch,  Joiim.  Amer.  Med.  Assoc,  1909,  p.  1386. 


XII]  HYDRONEPHROSIS  185 

LITERATURE— co?i<mMC(Z 

Carstair  and  Muir,  Brit.  Med.  Journ.,  190-t,  i.  13G. 
Gardner,  ylnn.  Surg.,  1908,  p.  575. 
Helferich,  Deuts.  Zeits.  f.  Chir.,  1890,  p.  323. 
Israel,  Dcuts.  med.   Woch.,  1906,  p.  22. 
Krogius,  Oentralbl.  f.  Chir.,  1902,  p.  686. 
Kiister,  Arch.  f.  klin.   Chir.,  1892,  p.  850. 
Lindermann,  Zeits.  /.  klin.  Med.,  1898,  p.  299. 
Luys,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1906,  i.  579. 
Mayo,  Journ.  Amer.  Med.  Assoc,  1909,  p.  1383. 
Morley,  Lancet,  June  11,  1910. 
Schloffer,  Wien.  klin.  Woch.,  1906,  p.  50. 

Trendelenburg,  Volhmanns  Sammhmg  klin.  Vortr.,  1890,  p.  355., 
Viertel,  Centralbl.  f.  Chir.,  1896,  p.  9. 
;  Vblcker  und  Lichtenberg,  Beitr.  z.  klin.  Chir.,  1907,  p.  1. 

Wagner,  Folia  Urol.,  June,  1907. 

Walker,  Thomson,  Lancet,  Aug.  11,  1906,  and  June  17,  1911; 
Trans.  Med.  Soc.  Lond.,  1912. 


CHAPTER  XIII 
TUMOURS  OF  THE  KIDNEY  AND  URETER 

TUMOURS  OF  THE  KIDNEY 

New  growths  are  found  in  greater  variety  in  the  kidney  than 
elsewhere  in  the  body.  Benign  growths  of  the  kidney  are  few 
and  rare,  but  mahgnant  growths  are  more  common.  Here  as 
elsewhere,  the  border-line  between  innocence  and  malignancy  is 
ill  defined.  Secondary  growths  in  the  kidney  are  infrequent. 
They  occur  as  a  part  of  a  widespread  metastatic  deposit,  and 
are  of  no  surgical  importance. 

BENIGN   GROWTHS 

Benign  growths  form  less  than  7  per  cent,  of  renal  growths. 
They  are  more  interesting  from  a  pathological  than  from  a  surgical 
standpoint. 

Adenoma 

Adenomas  occur  as  small  tumours,  and  may  reach  the  size  of 
a  cherry.  They  are  subcapsular,  usually  single,  but  may  be 
multiple,  round  or  nodular,  greyish-white  or  pink  in  colour,  and 
surrounded  by  a  distinct  capsule.  They  usually  occur  in  kidneys 
which  show  chronic  interstitial  nephritis. 

Two  varieties  are  described — a  papillary,  which  consists  of 
acini  lined  with  cylindrical  epithelium  and  containing  papillary 
formations;  and  an  alveolar  or  tubular  form,  consisting  of  solid 
or  hollow  masses  of  cylindrical  epithelium. 

Lipoma 
Lipomas  are  usually  small   multiple  tumours,  situated  under- 
neath the  capsule.     (Eig.   46.)    Very  rarely  a  large  lipoma  has 
been  observed. 

Fibroma 
Pure  fibromas  are  extremely  rare.     They  have  been  found  as 
small  fibrous  nodules  in  the  cortex  or  medulla. 

186 


CHAr.  XIIl] 


RENAL  TUMOURS 


187 


Leio  Myoma 
This  is  a  very  rare  form  of  growth  of  the  kidney,  occurring  as 
small  nodules  of  smooth  muscle  fibres  originating  in  the  smooth 
muscle  of  the  capsule  of  the  kidney  {see  under  Perirenal  Tumours, 
p.  220). 

Diagnosis  of  benign  renal  tumours. — The  diagnosis  of  simple 
groAvths  of  the  kidney  is  very  difficult.  Those  of  small  size 
give  rise  to  no  symptoms  and  are  found  post  mortem.     Large 


Fig.  46. — Microscopical  section  of  lipoma  of  kidney. 

growths  are  indistinguishable  clinically  from  maHgnant  growths, 
and,  unless  a  positive  diagnosis  of  simple  growth  can  be  made  on 
exposing  the  kidney,  nephrectomy  should  be  performed. 

MALIGNANT   GROWTHS 

The  following  varieties  of  malignant  renal  tumours  are  found  : — 

1.  Carcinoma. 

2.  Sarcoma. 

3.  Hj^ernephroma. 

4.  Mixed  tumours  of  embryonic  type. 


188  THE   KIDNEY  [chap. 

I 

Of  434  cases  recorded  since  1903,  65  were  carcinomas,  74  sar- 
comas, 45  mixed  tumours,  218  hypernepliromas,  and  32  benign 
or  of  unknown  nature  (Taddei). 

A  renal  growth  is  most  prone  to  develop  at  the  two  extremes 
of  life,  the  great  majority  of  these  tumours  being  found  under 
5  or  over  40  years. 

Kiister  found  the  following  age-distribution  : — 


1-  5  years 
6-10       ,. 

40-50      .. 

51-60      „ 


128 

41 

125 

128 


The  right  kidney  is  more  'frequently  afEected  than  the  left,  and 
bilateral  renal  growths  are  rare.  Men  are  more  frequently 
affected  than  women  in  the  proportion  of  227  men  to  73  women 
(Albarran).  Any  part  of  the  kidney  substance  may  be  the  seat 
of  growth.  Occasionally  the  tumour  is  situated  immediately 
beneath  the  fibrous  capsule,  or  the  growth  may  take  origin 
in  the  renal  pelvis  or  in  the  tissues  at  the  hilum  or  around  the 
kidney. 

Etiology. — The  large  number  of  tumours  found  in  child- 
hood suggests  that  many  renal  growths  are  congenital,  and  the 
structure  of  the  mixed  tumours  found  in  infancy  and  childhood 
supports  this  view.  There  is  no  direct  evidence  that  injury  is  a 
cause,  but  an  injury  to  the  kidney  may  draw  attention  to  a  new 
growth  which  already  exists. 

Stone  sometimes  coexists  with  new  growth  of  the  kidney,  but 
such  cases  are  too  rare  for  this  factor  to  play  an  important  role  in 
the  etiology. 

In  a  few  cases  a  new  growth  has  been  found  in  a  movable 
kidney.  It  is  said  that  such  kidneys  are  more  exposed  to  trauma 
and  that  this  may  be  a  cause  of  new  growth. 

Pathology  and  histology.  1.  Carcinoma. — In  recent  years 
it  has  been  shown  that  carcinoma  of  the  kidney  is  a  rare  form 
of  tumour,  and  that  many  of  the  growths  formerly  regarded  as 
carcinomas  belong  to  the  group  known  as  hypernephromas. 
Garceau  states  the  frequency  of  carcinoma  as  7  per  cent,  of 
renal  tumours.  The  new  growth  takes  origin  in  the  tubules  of 
the  kidney.     (Fig.  47.) 

The  following  three  varieties  of  histological  structure  are 
found : — 

i.  Diffuse  infiltration  of  the  interstitial  tissue,  tubules,  and 
glomeruli  by  cancer  cells.  In  parts  the  cells  are 
arranged  in  masses  or  in  alveoli. 


XIll] 


RENAL    CARCINOMA 


189 


ii.  Tubules    lined    with    epithelium    closely    resembling   the 

structure  of  the  normal  kidney, 
iii.  Acini  into  which  papillary  growths  project. 
The  first  and  second  varieties  are  frequently  found  in  the 
same  tumour,  and  the  name  adeno-carcinoma  is  sometimes  given 
to  this  type  (Fig.  48).     The  third  variety  may  form  a  characteristic 
tumour,  and  is  then  called  papillary  adeno-carcinoma. 


H      ft'  ♦  •  C        ^''  \ 


W\0 


Fig.  47. — Microscopical  section  of  carcinoma  of  kidney. 

Garceau  points  out  that  the  histological  appearances  may  vary 
greatly  in  the  same  specimen,  and  that  in  some  tumours  which 
closely  resemble  renal  carcinoma  the  metastases  have  the  appear- 
ance of  a  hypernephroma. 

The  kidney  may  retain  its  natural  outline  in  the  infiltrating 
form  of  carcinoma.  The  growth  is  usually  small,  but  occasionally 
reaches  a  large  size.  On  section  it  is  grey,  yellow,  or  brown,  and 
is  broken  up  by  tracts  of  comiective  tissue. 

2.  Sarcoma  (Fig.  49). — Sarcoma  is  more  often  bilateral  than 
carcinoma,  and  is  especially  found  in  infants  (82  adults,  80  infants 
— Albarran  and  Imbert).     In  adults  the  tumour  is  rarely  larger 


190 


THE   KIDNEY 


[chap. 


than  an  infant's  head,  but  in  children  it  may  reach  enormous 
proportions.  A  tumour  of  this  nature  weighing  33  lb.  has  been 
described  by  Van  der  Byl. 

The  growth  increases  rapidly  in  size,  and  quickly  forms 
adhesions  to  the  surrounding  structures. 

Some  of  these  growths  arise  from  the  capsule  of  the  kidney 
and  others  from  the  connective  tissue  surrounding  the  vessels  at 


Fig.  48. — Microscopical  section  of  adeno-carclnoma  of  kidney. 

the  hilum,  but  the  great  majority  take  origin  in  the  substance  of 
the  kidney. 

On  section  the  sarcoma  has  a  greyish,  brain-like  appearance, 
and  in  parts  an  alveolar  arrangement  may  be  observed.  It  is 
limited  on  the  surface  by  the  fibrous  renal  capsule,  and  separated 
from  the  parenchyma  by  a  fibrous  capsule  which  may  be  ill 
defined  at  parts.  The  histological  varieties  of  sarcoma  are  the 
spindle-celled  and  small  round-celled. 

Angio-sarcoma  of  the  kidney  has  been  described,  but  these 
growths  are  now  included  in  the  group  of  hypernephromas,  with 
which  they  are  identical. 


XIIl] 


RENAL  HYPERNEPHROMA 


191 


3.  Hypernephroma. — Under  this  name  are  placed  tumours 
of  the  kidney  which  resemble  the  suprarenal  gland  in  their  his- 
tological appearances.  These  tumours  were  described,  in  1883, 
by  Grawitz,  who  held  that  they  took  origin  in  small  aberrant 
nodules  of  suprarenal  tissue  found  in  the  cortex  of  the  kidney, 
usually  beneath  the  capsule.  In  the  embryo  the  suprarenal  gland 
surrounds  the  kidney,  and  portions  of  suprarenal  tissue  become 
included  in  the  kidney  in  the  process  of  development. 


Fig.  49. — Microscopical  section  of  kidney  infiltrated  by 
lympho-sarcoma. 

Recent  observations  on  the  embryology  of  the  suprarenal  gland 
appear  to  show  that  it  is  formed  from  mesoblastic  cells  (Poll), 
and  these  new  growths  should  therefore  be  looked  upon  as  sar- 
comas. The  point  is  not  finally  settled,  and  it  is  convenient  to 
classify  the  growths  separately  under  the  name  of  hypernephroma. 

Stoerk  has  recently  disputed  the  suprarenal  origin  of  these 
growths.  He  looks  upon  them  as  papillomatous  in  nature.  Ac- 
cording to  this  observer  they  are  adenomas,  or  papilliferous  cysts, 
or  carcinoma,  and  take  origin  in  the  renal  epithelium.  Wilson  and 
Willis  hold  that  they  arise  in  remains  of  the  Wolffian  body.     The 


192 


THE  KIDNEY 


[chap. 


tumours  are  most  frequently  found  under  the  capsule,  and  have 
no  covering  of  renal  tissue.  Kiister  found  80  situated  in  the 
middle,  54  at  the  upper  and  60  at  the  lower  pole  of  the  kidney. 
The  medulla  of  the  kidney  may  be  the  seat  of  a  hypernephroma. 
The  right  kidney  is  more  frequently  affected  than  the  left  (82-77), 
and  male  subjects  more  often  than  female  (102-71) — Garceau. 
The  tumour  is  very  rarely  bilateral. 


Fig.  50. — Microscopical  section  of  hypernephroma  of  kidney, 
papillary  type. 

This  is  the  most  frequent  form  of  new  growth  in  the  kidney. 
Of  102  tumours  of  the  kidney  68  were  of  this  nature  (Israel). 

The  growth  may  become  active  and  give  rise  to  chnical  symp- 
toms at  any  age.  Garceau's  table  of  176  cases  shows  48  between 
the  ages  of  40  and  50,  61  between  those  of  50  and  60,  and  24 
between  those  of  60  and  70. 

The  tumour  consists  of  a  rounded  mass  of  varying  size.  (Plate 
10.)  On  section  it  is  surrounded  by  a  capsule  of  firm  fibrous  tissue, 
often  of  considerable  thickness.  The  substance  of  the  growth  is 
broken  up  by  fibrous  bands  into  nodules  of  different  sizes.    (Plate  11.) 


Hypernephroma  of  kidney ;  operation  specimen, 
surface  view.  Note  renal  vein  distended  with 
growth,  and  aberrant  renal  artery  passing  to 
upper  pole.     (P.  192.) 


Plate  10. 


Section   of  hypernephroma   of  kidney.     Note   vein   distended  with 
growth.     Same  kidney  as  in  Plate  10.     (P.   192.) 


Plate  11. 


XIIl] 


RENAL  HYPERNEPHROMA 


193 


These  may,  however,  be  absent,  when  tlie  growtli  presents  a  more 
uniform  appearance.  There  is  a  characteristic  yellow-red  colour 
which  is  found  in  most  of  these  growths,  and  is  due  to  the  presence 
of  a  large  quantity  of  fat  in  the  cells  of  a  very  vascular  growth. 
Patches  of  necrosis  arc  not  infrequently  seen,  and  hemorrhages 
sometimes  take  place  in  the  substance  of  the  growth.  The  micro- 
scopical appearances  resemble  the  cortex  of  the  suprarenal  gland. 


Fig.  51. — Microscopical  section  of  hypernephroma  of  kidney, 
alveolar  type. 

The  growth  consists  of  a  network  of  capillary  vessels,  and  set 
directly  upon  these,  without  the  intervention  of  connective-tissue 
fibres,  are  the  tumour  cells.  These  are  large  polyhedral  cells 
"with  clear  protoplasm  containing  a  quantity  of  fat.  There  is  a 
large  nucleus  with  a  distinct  nucleolus.  The  cells  are  arranged 
around  the  capillary  vessels  in  a  single  row  or  several  rows. 
Where  a  single  row  or  relatively  few  rows  of  cells  lie  on  the  capil- 
laries a  papillary  appearance  is  given  (Fig.  50) ;  when  the  spaces 
between  the  capillaries  are  filled  up  with  closely  packed  cells  an 
alveolar  appearance  is  presented  (Fig.  51).     According  to  Garceau 

N 


194  THE   KIDNEY  [chap. 

the  alveolar  arrangement  is  more  frequently  seen  in  large  growths 
than  the  papillary. 

4.  IVIixed  tumours. — These  tumours  are  found  during  the 
first  four  years  of  life.  They  are  formed  of  tissues  arising  from  the 
three  layers  of  the  embryo.  The  basis  of  the  tumour  consists  of 
connective  tissue  of  a  more  or  less  embryonic  type^  the  cells  being 
round,  oval,  and  spindle-shaped  in  varying  proportions.  In  this 
are  found  striped  muscle  fibres  in  an  embryonic  stage  of  develop- 
ment, the  fibres  lacking  sarcolemma  and  the  nuclei  lying  at  the 
side  of  the  fibres.  Non-striped  muscle  fibres,  cartilaginous  nodules,- 
fatty  tissue,  elastic  tissue,  and  epithelial  elements  in  the  form 
of  tubules  are  also  found.  There  is  considerable  variation  in 
the  proportions  and  arrangement  of  these  elements.  When  the 
striped  muscle  fibres  are  present  in  large  numbers  the  growth  is 
termed  a  "  rhabdo-myo-sarcoma."  When  the  epithelial  elements 
are  numerous  the  name  "  embryonic  adeno-sarcoma "  is  used. 
Bland-Sutton  holds  that  when  the  striped  cells  are  very  abundant 
the  tubules  are,  as  a  rule,  absent. 

These  growths,  as  Bland-Sutton  points  out,  arise  in  the  tissues 
of  the  sinus  of  the  kidney  and  distend  the  organ,  so  that  a  thin 
layer  of  expanded  kidney  tissue  can  be  found  covering  the 
growth.  Eventually  the  capsule  is  ruptured  and  the  growth 
spreads  beyond  the  organ. 

The  ureter  is  not  usually  invaded,  and  this  accounts  for  the 
absence  of  hsematuria  which  is  noted  in  these  cases. 

Growth  into  the  renal  veins  and  inferior  vena  cava  is  almost 
invariable,  and  may  give  rise  to  embolism  or  to  oedema  and  ascites. 
The  disease  is  bilateral  in  about  50  per  cent,  of  cases. 

Extension  and  metastases. — Some  forms  of  renal  growth, 
especially  hypernephroma  and  mixed  growths,  are  prone  to  spread 
along  the  renal  veins,  and  buds  may  extend  into  the  vena  cava. 
From  this  fragments  may  be  swept  into  the  right  side  of  the  heart 
and  the  pulmonary  artery.  This  extension  may  give  rise  to  diflS.- 
culty  in  ligaturing  the  vessels,  or  to  tearing  of  the  renal  vein  at 
operation.  Spread  through  the  capsule  of  the  kidney  takes  place 
in  large  growths.  Examination  of  the  perirenal  adhesions  and 
adipose  tissue  occasionally  shows  microscopic  nodules  of  growth 
when  nothing  is  seen  with  the  naked  eye.  In  the  later  stages 
neighbouring  organs  and  nerves  are  invaded.  Extension  along 
the  lymphatics  to  the  lymph-glands  lying  alongside  the  aorta  and 
vena  cava  usually  occurs  late.  Lymphatic  glands  at  the  root  of 
the  neck  and  groin  have  been  the  seat  of  deposit  in  rare  cases. 
The  suprarenal  capsule  is  very  frequently  invaded  by  tumours 
of  the  upper  pole  of  the  kidney.     In  the  majority  of  adult  cases 


XIII]  RENAL   GROWTHS  195 

the  growth  invades  the  pelvis,  where  rarely  it  forms  a  pedunculated 
tumour.  In  children  the  pelvis  is  usually  free  from  growth.  From 
the  pelvis  the  growth  may  spread  down  the  ureter  and  project 
into  the  bladder,  or  a  portion  may  become  detached  and  be  held 
for  a  time  at  the  ureteric  orifice  or  engrafted  on  the  ureter.  Metas- 
tases may  occur  early  in  hypernephroma  when  the  primary  growth 
is  still  small,  or  the  renal  growth  after  a  period  of  slow  develop- 
ment may  suddenly  increase  rapidly  and  form  metastases.  Hyper- 
nephromas are  specially  prone  to  form  metastases  in  bones. 

In  children  lymphatic  glands  may  be  affected  late,  but  there 
is  frequently  no  deposit  apart  from  the  kidneys. 

The  most  common  seats  of  metastatic  deposit  are  the  lungs, 
liver,  lymph-glands,  and  bones,  and  more  rarely  the  second  kidney, 
pleura,  omentum,  suprarenal  gland,  and  brain. 

Concomitant  diseases  of  the  kidneys,  such  as  stone,  movable 
kidney,  and  tuberculosis,  have  been  observed  with  new  growth, 
but  these  conditions  have  no  etiological  value. 

The  kidney  which  rs  the  seat  of  a  new  growth  shows  fibrous 
induration  in  the  neighbourhood  of  the  tumour,  the  result  of 
compression.  There  is  also  epithelial  and  interstitial  nephritis 
in  this  and  in  the  second  kidney,  due  to  the  absorption  of  toxins 
from  the  growth  (Albarran).  '  This  diminishes  the  functional 
value  of  the  second  kidney,  and  may  be  the  cause  of  death  after 
nephrectomy. 

Obliteration  of  the  ureter  by  portions  of  growth  or  by  com- 
pression may  give  rise  to  hydronephrosis,  and  accumulation  of 
clots  in  the  pelvis  may  produce  a  haematonephrosis.  Chronic 
myocarditis  from  the  circulation  of  toxins  is  frequently  present, 
and  is  a  cause  of  heart  failure  after  nephrectomy  (Israel). 

Symptoms. — The  cardinal  symptoms  of  new  growth  of  the 
kidney  are  hsematuria  and  tumour. 

Hcematuria  is  the  most  constant  symptom  and  usually  the 
first  to  appear.  In  adults  it  is  present  in  over  90  per  cent,  of 
cases,  and  is  the  first  symptom  in  70  per  cent.  In  children  it 
is  much  less  frequent,  occurring  in  only  about  16  per  cent,  of 
cases,  and  it  is  rarely  present  until  after  an  abdominal  tumour  is 
discovered.  The  first  appearance  of  hsematuria  sometimes  follows 
a  strain  or  blow  on  the  loin,  but  the  initial  attack  and  subse- 
quent attacks  are  usually  spontaneous.  It  is  intermittent  and 
capricious.  Blood  appears  without  cause,  and  lasts  a  day  or  a 
week  or  longer,  and  then  disappears  for  an  indefinite  period,  an 
interval  of  a  week,  a  month,  six  months,  or  a  year  occurring  before 
the  next  attack.  Rest  in  bed  may  be  followed  by  disappearance 
of  the  blood,  but  often  it  does  not  influence  the  attack. 


196  THE   KIDNEY  [chap. 

The  blood  is  well  mixed  with  the  urine,  and  may  be  dark 
purple,  or  bright  red,  or  only  a  pink  tinge.  When  the  urine  appears 
clear,  blood  cells  may  be  found  with  the  microscope. 

Clots  are  frequently  present,  and  slender  worm-like  clots  10 
or  12  in.  long  are  sometimes  passed.  (Fig.  52.)  Israel  describes 
a  special  form  of  clot  found  in  new  growth  of  the  kidney.     The 

clots  are  the  size  and  shape 
of  maggots,  are  red,  pale 
yellow,  or  white,  and  are 
contracted  at  parts.  They 
occur  in  a  shghtly  bloody 
urine. 


Clots  may  block  the  lumen 
of  the  ureter  and  give  rise  to 
attacks  of  ureteral  cohc,  with 
sudden  disappearance  of  the 
blood  in  the  urine.  Copious 
Fig.  52.— Ureteral  clots  in  renal  haemorrhage  _  may  fill  the 
haematuria.  bladder    rapidly    with    clots 

and  cause  strangury. 
The  haematuria  has  no  relation  to  the  size  of  the  growth.     A 
small    growth    may    cause    copious    and    repeated    haemorrhages, 
while  the  haemorrhage  from  a  large  growth  may  be  scanty  and 
occur  at  long  intervals. 

Haematuria  occurs  in  all  forms  of  renal  growth.  It  is  least 
frequent  in  the  mixed  sarcomas  of  children  and  infants. 

Tumour  is  a  very  frequent  symptom.  It  is  present  in  the 
advanced  stage  of  nearly  all  growths  (84  per  cent. — Albarran  and 
Imbert).  It  is  less  often  than  haematuria  the  first  symptom  (23 
per  cent. — ^Heresco).  In  children,  however,  tumour  is  almost  con- 
stant (140  in  142  cases — Walker),  and  is  the  initial  symptom  in 
about  one-third  of  cases. 

The  kidney  can  usually  be  felt  enlarged  when  haematuria  first 
appears.  When  the  new  growth  is  situated  at  the  upper  pole  it 
is  not  palpable  until  it  has  reached  a  large  size.  The  kidney  is, 
however,  pushed  down  and  can  be  felt  lower  than  normal.  Small 
tumours  of  the  lower  pole  can  be  detected  in  favourable  subjects. 
Israel  felt  a  tumour  the  size  of  a  nut  in  this  position. 

A  large  growth  is  easily  felt,  and  has  the  characters  of  a  renal 
tumour.  (Fig-  53.)  It  forms  a  rounded  mass  occupying  the  loin. 
On  percussion  a  dull  note  is  given,  and  there  is  usually  a  resonant 
band  formed  by  the  colon  on  the  surface  of  the  tumour,  or  the 
flattened  colon  can  be  roUed  under  the  finger.  The  colon  may 
be  distended  with  aic  to  assist  the  examination.     The  tumour  is 


XIII]  RENAL   GROWTHS:   SYMPTOMS  197 

rounded,  and  frequently  smooth,  and  is  firm  and  resistant.  There 
may  be  nodular  irregularities,  and  some  parts  of  a  large  growth  can 
oceasionallv  be  felt  less  resistant  than  others.  The  mass  extends 
backwards  into  the  loin,  and  can  be  felt  here  with  the  fingers  below 
the  12th  rib.  When  it  is  small  the  sensation  of  ballottement  can 
be  detected  by  projecting  it  forwards  from  the  loin  against  the 
hand  laid  flat  on  the  abdomen.  In  a  large  growth  the  mass  is 
already  in  contact  with  the  abdominal  wall,  and  this  sensation  is 
lost.  The  tumour  usually  moves  with  respiration,  and  retains  this 
character  until  it  has  reached  a  large  size.      If  it  is  fixed,  and 


Fig.  53. — Visible  tumour  in  case  of  large  renal  growth. 

especially  when  the  tumour  is  still  small,  adhesions  have  already 
formed. 

When  masses  of  enlarged  glands  he  along  the  aorta  they  may 
be  continuous  with  the  timiour  on  palpation,  and  a  large  irregular 
mass  is  felt. 

Pain  is  a  common  symptom,  and  is  due  to  a  variety  of  causes. 
Attacks  of  ureteral  colic  are,  as  already  mentioned,  produced  by 
the  passage  of  clots  along  the  ureter.  Severe  aching  renal  pain 
may  be  due  to  tension  within  the  renal  capsule,  caused  by  engorge- 
ment of  the  kidney  or  haemorrhage  into  the  growth.  Constant 
aching  pain  unaffected  by  movement,  or  by  the  variations  in 
the   hsematuria,  and   only  temporarily  reheved    by  drugs,  is   the 


198  THE   KIDNEY  [chap. 

characteristic  pain  of  renal  cancer.  It  is  caused  by  the  spread  of 
the  growth  beyond  the  kidney  and  the  involvement  of  nerves.  It 
may  take  the  form  of  intercostal  neuralgia,  or  may  radiate  to 
the  genital  organs  or  down  the  thigh.  I  have  known  constant 
sciatica-like  pain  precede  by  some  months  the  onset  of  hsematuria 
and  the  appearance  of  enlargement  of  the  kidney. 

Changes  may  be  present  in  the  urine  apart  from  hsematuria. 
Occasionally  portions  of  growth  are  passed  in  the  urine,  the 
nature  of  which  can  be  recognized  by  the  microscope.  Cancer 
cells  are  said  to  be  present  in  the  urine  in  some  cases,  but  it  is 
very  doubtful  if  these  are  not  cells  derived  from  the  epithelium  of 
the  renal  pelvis.  The  absence  of  such  formed  elements  has  no 
diagnostic  importance. 

Albumin  may  be  due  to  a  small  quantity  of  blood  which  cannot 
be  detected  with  the  naked  eye,  or  it  may  be  due  to  toxic  nephritis. 
Pyuria  is  present  in  the  rare  cases  where  calculus  coexists  with 
growth. 

The  quantity  of  urine  is  frequently  increased,  the  polyuria 
being  due  to  the  higher  pressure  in  the  renal  vessels. 

Varicocele  is  sometimes  observed.  It  develops  steadily,  some- 
times rapidly.  It  may  be  an  early  symptom,  and  may  already  be 
present  when  the  first  hsematuria  appears,  but  it  usually  develops 
late  in  the  course  of  the  disease.  It  is  due  to  pressure  either  of 
enlarged  glands  or  of  the  growth  itself,  or  it  may  be  produced 
by  engorgement  of  the  capsular  veins  which  anastomose  with  the 
spermatic  vein.  It  disappears  after  nephrectomy,  and  should  not 
be  considered  a  contra-indication  of  operation. 

Hochenegg  states  that  if  the  varicocele  does  not  disappear  in 
the  genu-pectoral  position,  it  is  due  to  compression  of  enlarged 
glands  and  the  growth  is  inoperable. 

Cachexia  occurs  in  the  late  stages.  It  is  sometimes  present, 
but  is  never  a  pronounced  feature  in  the  early  stage  of  the 
growth. 

Israel  has  described  a  specific  fever  in  8  per  cent,  of  cases  of 
new  growths  of  the  kidney  which  may  occur  early  or  late  in  the 
course  of  the  disease,  and  may  be  remittent  or  recurrent,  or 
there  may  be  occasional  attacks.  It  disappears  after  complete 
nephrectomy. 

Hypertrophy  of  the  left  ventricle  is  frequently  observed.  In- 
creased arterial  tension  has  been  observed  by  some  authorities, 
and  it  is  stated  that  these  patients  die  of  cerebral  haemorrhage. 
This  has  been  attributed  to  the  absorption  of  increased  quantities 
of  suprarenal  secretion  in  cases  of  hypernephroma.  An  abnormally 
rapid  pulse  is  not  uncommon,  and  is  said  to  be  due  to  pressure  on 


XIII]  RENAL  GROWTHS:     DIAGNOSIS  I'M 

the  lumbal"  sympatlietic  r,'aiiglia.  This  syinptoiii  is  common  to 
other  larj,'e  growths  in  the  lower  part  of  the  body. 

The  X-rays  give  a  dense  shadow  with  indefinite  outline  in  large 
growths  of  the  kidney.  Metastatic  nodules  in  the  lungs  are  clearly 
shown  by  the  X-rays  (Plate  9,  Fig.  3),  and  this  method  of  ex- 
amination should  be  used  before  operation  in  every  case.  The 
symptoms  of  pulmonary  metastases  may  be  insignificant  (Plate  9, 
Fig.  3). 

Course  and  prognosis. — Symptoms  are  frequently  present 
for  a  number  of  years  before  the  patient  is  submitted  to  operation. 
Kronlein,  Israel,  and  Loumeau  operated  on  patients  respectively 
eight,  twelve,  and  fifteen  years  after  the  first  symptom.  The 
general  health  may  remain  unaffected  for  four,  eight,  or  ten  years. 

Garceau  found  that  the  average  duration  of  the  disease  from 
the  appearance  of  the  first  symptom  to  the  fatal  issue  in  32  cases 
was  three  and  a  half  years.  The  course  is  rapid  where  metas- 
tases have  appeared. 

Diagnosis.  1.  Cases  where  hsematuria  is  the  only 
symptom. — Here  the  character  of  the  hsematuria  may  assist,  but 
cystoscopic  examination  during  an  attack  of  hsemorrhage  is  the 
only  certain  method  of  localizing  the  source  of  the  bleeding. 
Beyond  the  localization  of  heematuria  to  one  kidney  it  is  seldom 
possible  to  go  in  these  cases.  The  presence  of  cancer  cells  or  of 
portions  of  growth  in  the  urine  is  a  rare  and  doubtful  means  of 
diagnosis.  Exploration  of  the  bleeding  kidney  is  the  only  certain 
method,  and  this  should  be  carried  out  in  every  case  of  uni- 
lateral renal  hsematuria  in  which  the  diagnosis  cannot  be  clearly 
established. 

2.  Cases  where  tumour  is  the  only  symptom.  —  The 
characters  of  the  renal  tumour  have  been  described.  In  moderate- 
sized  tumours  the  diagnosis  presents  little,  if  any,  difficulty,  but 
in  large  growths  there  may  be  difficulty. 

Tumours  of  the  suprarenal  gland,  liver,  gall-bladder,  spleen, 
omentum,  and  colon  are  the  cause  of  the  most  frequent  mistakes. 
Sometimes  an  exploratory  laparotomy  may  become  necessary 
before  the  diagnosis  is  established. 

3.  Tumour  with  haematuria,  without  other  symptoms. 
— ^No  other  disease  of  the  kidney  gives  rise  to  this  combination 
of  symptoms.  Stone  has  pain  and  pyuria  in  addition,  and  tuber- 
culosis has  pyuria  and  the  tubercle  bacillus  is  discovered.  In 
congenital  cystic  degeneration  of  the  kidney  there  is  rarely  hsema- 
turia. In  this  disease  the  bilateral  tumour  and  the  long  and  very 
slow  development  will  suggest  the  true  nature  of  the  disease,  which 
an  exploratory  operation  will  confirm. 


200  THE   KIDNEY  [chap. 

It  is  rarely  possible  to  make  a  diagnosis  of  the  variety  of  growth 
before  operation.  In  children  the  frequent  growths  are  mixed 
sarcomas,  but  hypernephroma  has  been  observed  at  the  age  of 
1|  years  (Cheeseman).  The  presence  of  metastatic  deposits  in 
bones  is  characteristic  of  hypernephroma. 

Treatment. — Palliative  treatment  is  adopted  in  cases 
which  are  unsuitable  for  nephrectomy.  It  consists  in  the  admin- 
istration of  such  drugs  as  ergot,  adrenalin,  opium,  and  calcium 
lactate  to  control  haemorrhage,  and  opium,  morphia,  bromides, 
aspirin,  and  phenacetin  to  soothe  pain;  and  attention  to  the 
bowels,  since  the  pressure  and  adhesions  of  the  growth  may 
cause  obstinate  constipation. 

Calcium  lactate  should  be  administered  with  caution,  as  it 
encourages  the  formation  of  clots  and  may  give  rise  to  clot 
colic.  Palliative  operations,  such  as  nephrectomy  where  there  are 
secondary  growths,  or  partial  nephrectomy  for  pain,  are  seldom 
called  for. 

Radical  treatment  by  total  nephrectomy,  performed  as 
early  as  possible,  is  the  only  method  which  holds  out  a  prospect 
of  cure.  Partial  nephrectomy  is  unsuited  to  the  treatment  of 
malignant  growth  of  the  kidney. 

Operation  is  contra-indicated  where  (1)  the  growth  has  spread 
beyond  the  kidney,  (2)  the  second  kidney  is  functionally  inade- 
quate, (3)  the  patient  is  weak  and  cachectic,  (4)  the  heart  is  dilated 
and  feeble. 

It  is  therefore  necessary  to  ascertain,  before  proceeding  to 
nephrectomy,  whether  the  growth  has  spread  beyond  the  kidney. 
Where  the  kidney  is  still  small  the  disappearance  of  movement 
on  respiration  is  an  important  sign  of  spread  beyond  the  kidney, 
but  immobility  in  a  large  tumour  has  not  the  same  significance. 
The  extent  of  the  growth  can  best  be  ascertained  after  exposure 
of  the  kidney. 

In  all  large  growths  the  peritoneum  should  be  opened  and  the 
peritoneal  aspect  of  the  tumour  examined.  The  upper  pole  of  the 
kidney  can  at  once  be  explored  by  this  means,  whereas  it  cannot 
be  reached  until  a  late  stage  of  the  operation  if  approached  extra- 
peritoneally.  I  have  twice  had  to  desist  from  nephrectomy  on 
finding  the  peritoneum  adherent  and  nodular  over  the  highest 
part  of  the  kidney  in  tumours  which  in  other  respects  appeared 
to  be  suitable  for  removal. 

The  lymph-glands  lying  alongside  the  aorta  or  the  vena  cava 
should  be  examined  by  palpation,  and  if  the  peritoneum  is  opened 
a  further  examination  should  be  made.  The  most  frequent  seat 
of  secondary  growths  is  the  lungs,  and  a  radiograph  of  the  thorax 


xni]   NEPHRECTOMY  FOR   RENAL  GROWTHS  201 

should  be  obtained.      The  liver  should  be  examined  by  palpation 
and  percussion. 

The  condition  of  the  second  kidney  is  ascertained  by  cathe- 
terization of  the  ureters  and  examination  of  the  urine  thus  obtained, 
and  the  use  of  the  tests  for  the  renal  function.  The  presence  of 
chronic  nephritis  does  not  contra-indicate  operation  if  the  renal 
function  is  adequately  performed. 

The  ideal  operation  should  remove  the  kidney  and  growth, 
the  adipose  capsule,  the  lymphatic  vessels  and  glands  and  the 
fat  in  which  they  are  embedded,  and  the  suprarenal  capsule. 
Nephrectomy  may  be  performed  by  the  abdominal  (transperitoneal) 
or  lumbar  (retroperitoneal)  route. 

At  the  present  day,  in  a  considerable  proportion  of  cases  the 
operation  commences  as  an  exploration  of  the  kidney  for  heema- 
turia  before  any  enlargement  of  the  kidney  can  be  detected,  and 
the  discovery  of  the  growth  leads  to  nephrectomy.  In  such  cases 
the  operation  commences  as  a  retroperitoneal  exploration  of  the 
kidney,  and  when  the  growth  is  discovered  the  adipose  capsule 
has  already  been  opened  and  the  kidney  incised.  The  incision  in 
the  kidney  should  be  closed  with  catgut  sutures  and  nephrectomy 
performed.  '? 

The  perirenal  fat  should  then  be  dissected  from  the  peritoneum 
and  from  the  muscles  of  the  posterior  abdominal  wall.  This 
should  be  carried  inwards  as  far  as  the  great  vessels,  preserving 
the  spermatic  vessels,  and  carefully  removing  the  lymph-glands 
along  the  aorta  or  the  vena  cava.  The  suprarenal  glands  should 
also  be  removed. 

Where  a  diagnosis  has  been  made  before  operation  in  larger 
growths  abdominal  nephrectomy  will  give  a  better  approach,  or 
the  growth  may  be  exposed  by  the  lumbar  retroperitoneal  route 
and  the  peritoneum  opened  to  the  outer  side  of  the  colon. 

Gregoire  has  described  an  operation  which  is  to  be  recommended 
when  a  diagnosis  of  new  growth  has  been  made. 

A  firm  pillow  is  placed  imder  the  diseased  side  as  far  as  the 
vertebral  column,  and  the  body  is  curved  backwards. 

The  incision  runs  in  the  anterior  axillary  line  from  the  costal 
margin  to  the  iliac  crest,  and  each  end  of  this  is  carried  forwards 
for  4  or  5  cm.  along  the  costal  margin  and  ihac  crest  respectively. 
This  is  carried  through  the  muscles,  and  the  peritoneum,  colon, 
and  perirenal  fascia  are  then  displaced  forwards  from  the  muscles 
of  the  posterior  abdominal  wall  as  far  as  the  vertebral  columin. 
The  fascia  of  Zuckerkandl  is  incised  1  cm.  behind  the  reflection  of 
the  peritoneum,  and  the  peritoneum  and  colon  are  stripped  for- 
wards.   The  upper  pole  of  the  kidney,  with  the  suprarenal  capsule, 


202  THE   KIDNEY  [chap. 

is  separated,  the  renal  vessels  are  ligatured,  the  ureter  is  tied,  and 
the  kidney  removed.  The  adipose  tissue,  lymphatics,  and  glands 
are  now  dissected  along  the  vena  cava  and  aorta,  preserving  the 
spermatic  vessels.  ■ 

Dangers  of  nephrectomy  for  renal  growth. — The  immediate 
danger  is  haemorrhage.  The  kidney  is  frequently  surrounded  by 
large,  dilated,  easily  torn  veins,  and  free  venous  haemorrhage, 
difficult  to  control,  may  take  place.  Formidable  veins  are  also 
met  with  at  the  upper  pole,  and  are  difficult  to  reach.  They  are 
controlled  by  a  temporary  packing  during  the  operation.  The 
renal  vein  is  easily  torn  when  it  is  filled  with  growth,  and  may 
give  rise  to  severe  haemorrhage.  The  inferior  vena  cava  has  been 
torn,  and  lateral  suture  has  been  performed  {see  Nephrectomy, 
p.  297).  Pulmonary  emboHsm  has  been  caused  by  the  separa- 
tion of  a  clot  or  portion  of  growth  in  the  renal  veins  during 
operation. 

The  wound  may  be  soiled  with  carcinomatous  tissue,  and  as 
a  result  recurrence  takes  place  in  the  scar. 

Anuria  may  supervene  from  inadequate  function  of  the  second 
kidney.  This  danger  should  not  arise  in  properly  selected 
cases. 

Cardiac  failure  may  occur  at  the  close  of  or  soon  after  the 
operation,  or  it  may  be  delayed.  Chronic  myocarditis  predisposes 
to  its  occurrence. 

Results. — The  mortahty  of  nephrectomy  for  renal  growths  has 
fallen  during  recent  years  from  76  per  cent.  (Minges,  1885)  and 
65-2  per  cent.  (Tuffier,  1888)  to  22  per  cent.  (Albarran  and  Imbert, 
1902).  Schmieden's,  statistics  of  329  cases  show  that  the  mortality 
during  the  first  ten  years  of  renal  surgery  was  64-3  per  cent.,  in 
the  second  ten  years  43-0  per  cent.,  and  in  the  third  22-0  per  cent, 
in  adults. 

The  high  death-rate  in  the  earlier  operations  was  largely  due 
to  septic  infection,  and  this  also  explained  the  higher  mortality  of 
transperitoneal  nephrectomy  as  compared  with  the  retroperitoneal 
operation. 

In  the  transperitoneal  operations  previous  to  1890  the  mor- 
tality was  50  per  cent.,  while  the  mortality  of  the  retroperitoneal 
operation  was  37  or  38  per  cent.  (Gross,  Brodeur). 

Operations  performed  after  1890  showed  a  mortality  of  23  per 
cent,  for  lumbar  and  21-1  per  cent,  for  transperitoneal  nephrectomy 
(Albarran  and  Imbert). 

Death  is  due  in  these  cases  to  septic  infection,  heart  failure, 
shock,  asthenia,  and  anuria. 

Late  results. — -Recurrence  takes  place  in  60  per  cent,  of  cases, 


xm]   NEPHRECTOMY  FOR   RENAL  TUMOURS  203 

and  in  over  70  per  cent,  of  these  it  appears  within  the  first  year. 
After  the  first  year  it  is  less  common,  and  it  is  rare  after  the  third 
or  fourth  year.  Cases  of  late  recurrence  after  three  years  have, 
however,  been  recorded  by  Bloch  (three  years),  Helferich  (three 
and  a  half  years).  Abbe  (four  and  a  half  years),  and  Witzel  (five 
years).  The  recurrent  growth  is  most  frequently  found  in  the 
scar.  It  occurs  also  in  the  lymph-glands,  lungs,  and  liver,  and 
in  these  cases  metastases  have  almost  certainly  taken  place  before 
the  operation. 

Forgue  found  that  28  cases  (7  to  10  per  cent.)  had  sur^dved  at 
the  end  of  the  fourth  year  without  recurrence.  Wagner  found 
21  cases  remaining  well  after  three  years  (16  adults,  5  children). 

Results  in  children. — In  children  the  operative  mortality  is 
higher,  and  recurrence  is  more  rapid  and  more  frequent  than  in 
the  adult.  Walker  states  the  general  mortality  from  operation 
and  recurrence  at  93-22  per  cent.,  while  Albarran  and  Imbert  give 
the  mortality  from  operation  as  25  to  30  per  cent.,  and  state  that 
recurrence  takes  place  in  between  67  and  81  per  cent,  of  survivals. 
Simon  has  collected  11  cases  in  good  health  a  year  after  the  opera- 
tion, during  which  the  longest  were — Israel  five  years,  Doder- 
lein  four  years,  Schmidt  three  years,  and  Shend  and  Rovsing  each 
two  years.  The  longest  survivalof  which  I  have  definite  infor- 
mation is  a  case  operated  on  by  Mr.  J.  D.  Malcolm,  in  November, 
1892,  which  was  well  in  February,  1911,  eighteen  years  and  three 
months  after  the  operation.  Abbe,  of  New  York,  recorded  two 
cases  of  prolonged  survival :  in  one  the  patient  died  of  new  growth 
in  the  remaining  kidney  four  and  a  half  years  after  operation ;  the 
other  patient  was  alive  and  well  over  ten  years  after  operation. 

LITERATURE 

Albarran  et  Imbert,  Les  Tumeurs  du  Rein.     Paris,  1903. 

Bland-Sutton,   Tumours,  Innocent  and  Malignant.     1911. 

Forgue,  VI«  Sess.  de  I'Assoc.  fran9.  d'Urol.,  Paris,  1902. 

Garceau,  Tumours  of  the  Kidney.     1909. 

Grawitz,  Virchows  Arch.,  1883,  p.  39. 

Gregoire,  These  de  Paris,  1905  ;    Presse  Med.,  1905,  p.  49. 

Hereseo,  These  de  Paris,  1899. 

Hochenegg,  Arch.  f.  Uin.  Med.,  1907,  p.  51. 

Israel,  Nierenkrankheiten,  1901  ;    Dents,  med.   Woch.,  1911,  p.  57. 

Poll,  Handbuch  der  vergl.  und  exper.   Entwickelungslehre  der  Wirbeltiere, 

p.  456.     Jena. 
Schmieden,  Deuts.  Zeits.  f.  Chir.,  1902. 
Simon,  These  de  Paris,  1904. 
Stoerk,  Zieglers  Beitr.,  1908,  p.  393. 
Taddei,  Foiia  Urol.,  1908,  pp.  303,  638. 
Trotter,  Lancet,  1909,  p.  1581. 

Wagner,  Handbuch  der  Urologie  (von  Frisch  und  Zuckerkandl),  1905,  ii.  273. 
Walker,  Ann.  Surg.,  1897,  p.  549. 
Wilson  and  Willis,  Collected  Papers  of  St.  Mary's  Hospital  (Mayo  Clinic),  1911. 


204 


THE  KIDNEY 


[chap. 


TUMOURS   OF   THE   RENAL  PELVIS  AND  URETER 

Tiie  majority  of  growths  of  the  kidney  project  into  the  pelvis. 
Primary  growths  of  the  pelvis  arise  apart  from  the  kidney,  and 
are  very  rare.  Albarran  collected  42  cases,  and  Israel  found  only 
2  primary  growths  of  the  pelvis  in  68  new  growths  of  the  kidney. 
Drew  described  a  case  of  villous  carcinoma  of  the  renal  pelvis 
and  collected  8  others  from  the  literature.  I  have  performed 
nephrectomy  on  2  such  cases. 


Fig.  54. — Papillomatous  growth  of  renal  pelvis,  with 
malignant  growth  of  kidney. 

Etiology. — Calculi  have  been  present  in  the  pelvis  in  some 
cases,  and  the  prolonged  irritation  caused  by  their  presence  may 
have  been  the  cause  of  the  growths.  Drew  found  calculi  in  4  out 
of  8  cases  collected  from  the  hterature. 

Pathology. — Epithehal  tumours  (papilloma  and  epithelioma) 
are  most  frequent,  while  mesoblastic  tumours  (sarcoma,  myxoma, 
rhabdomyoma,  lipoma)  are  rare. 

Papilloma  is  the  most  frequent  form  of  tumour  (22  in  54 — 
Albarran  and  Imbert).  The  tumour  is  situated  at  the  junction  of 
the  pelvis  and  ureter,  or  in  the  ureter,  usually  at  its  lower  end, 
or  may  extend  along  the  ureter  from  the  pelvis  and  may  protrude 


XIII]  GROWTHS   OF  RENAL   PELVIS  205 

into  the  bladder.  The  structure  and  appearance  closely  resemble 
papilloma  of  the  bladder.  These  tumours  are  simple,  but  show 
a  tendency  to  become  malignant.  The  malignant  form  of  papilloma 
is  less  frequent  than  the  simple  papilloma  (16  in  54  cases — Albarran 
and  Imbert),  and  has  the  same  appearance ;  but  on  microscopical 
examination  the  tumour  cells  are  found  infiltrating  the  wall  of 
the  pelvis  or  ureter.  The  growth  spreads  to  the  kidney  (Fig.  54) 
and  along  the  ureter,  and  a  graft  may  be  implanted  at  the  orifice 
of  the  ureter. 

Columnar-celled  carcinoma  is  less  frequent  and  forms  a  nodular 
growth.  Prolonged  inflammation  in  the  renal  pelvis  or  ureter 
causes  transformation  of  the  epitheUum  into  stratified  squamous 
epithehum,  and  patches  of  leucoplakia  are  produced.  In  this 
squamous-celled  epithehoma  may  arise.  These  tumours  spread 
rapidly  to  neighbouring  structures  and  the  lymphatic  glands,  and 
form  metastases. 

When  the  growth  is  situated  at  the  outlet  of  the  pelvis  or  in 
the  ureter  the  obstruction  produces  hydronephrosis,  and  if  haemor- 
rhage occurs  this  becomes  a  hsematonephrosis.  Pyonephrosis 
results  if  this  becomes  infected.  Wright  and  Morley  record  a  case 
of  hydronephrosis  in  a  horseshoe  kidney  caused  by  a  papilloma 
at  the  uretero-peMc  junction. 

Symptoms. — The  symptoms  resemble  those  of  growths  of  the 
kidney.  There  is  hsematuria  of  similar  characters,  together  with 
pain  and  tumour.  There  are  attacks  of  renal  retention  accom- 
panied by  intense  renal  and  ureteral  pain  and  rapid  enlargement 
of  the  kidney.  These  variations  in  size  are  much  greater  than  are 
observed  in  new  growths  of  the  kidney. 

On  cystoscopy  a  tumour  may  be  seen  projecting  from  the  ureter 
or  implanted  on  the  hp  of  the  orifice.  When  a  detached  portion 
is  caught  at  the  ureteric  orifice  it  will  be  passed  in  the  urine  in  a 
few  days,  and  a  later  cystoscopy  shows  the  orifice  free  from  growth. 
Catheterization  of  the  ureter  shows  an  accumulation  of  blood  and 
urine  in  the  renal  pelvis.  Cells  characteristic  of  the  growth  may 
be  found  in  the  fluid.  i 

Portions  of  papillomatous  growth  may  be  passed  in  the  urine 
after  attacks  of  renal  coUc  and  temporary  cessation  of  haemorrhage. 
In  a  case  under  my  care  these  fragments  had  been  passed  at  fre- 
quent intervals  for  four  years,  and  had  been  pronounced  benign 
in  character  by  an  able  pathologist.  The  kidney  then  began  to 
increase  rapidly  in  size,  and  I  removed  a  large  carcinomatous 
kidney  with  papillomatous  gro^^i^h  in  the  pehds. 

Diagnosis. — Diagnosis  may  be  difficult,  and  has  very  seldom 
been  made  before  operation.     The  most  important  points  are  the 


206  THE    KIDNEY  [chap,  xiii 

recognition  of  an  intermittent  hsematonephrosis  without  other 
renal  symptoms,  the  demonstration  of  columnar  or  squamous 
epithelium  in  the  fluid,  and  the  discovery  with  the  cystoscope 
of  a  tumour  projecting  from  the  ureteric  orifice. 

Where  portions  of  papillomatous  growth  are  passed  in  the 
urine  after  attacks  of  renal  colic  and  the  kidney  is  enlarged,  the 
diagnosis  is  readily  made. 

Prognosis. — The  prognosis  is  grave.  Simple  papillomas  may 
become  malignant,  and  the  malignant  growths  very  frequently 
recur  after  removal. 

Treatment. — In  tumours  of  the  pelvis  nephrectomy  is  indi- 
cated, whatever  the  nature  of  the  growth,  and,  if  the  ureter  appears 
to  be  affected  also,  nephrectomy  should  be  combined  with  ureter- 
ectomy. When  the  growth  is  situated  at  the  lower  end  of  the 
ureter  and  the  kidney  is  enlarged,  nephrectomy  followed  by  ureter- 
ectomy should  be  done.  It  may  be  necessary  to  remove  the  lower 
end  of  the  ureter  through  the  bladder  after  suprapubic  cyst- 
otomy. A  small  growth  at  the  ureteric  orifice  is  removed  in  the 
same  way  as  a  vesical  growth.  When  the  growth  in  this  position 
is  extensive  the  portion  of  the  bladder  wall  surrounding  the  ure- 
teric orifice  should  be  resected,  and  the  ureter  drawn  into  the 
bladder  and  cut  across  beyond  the  growth  and  implanted  into 
the  bladder  wound.  If  the  growth  extends  far  up  the  ureter 
it  may  be  necessary  to  approach  it  from  the  outside  of  the 
bladder  and  excise  the  diseased  segment,  and  then  implant  the 
ureter  high  up  in  the  bladder ;  and  if  the  growth  is  still  more 
extensive,  nephrectomy  should  be  performed.- 

Results. — Recurrence  has  taken  place  in  nearly  all  the  cases 
that  have  been  followed  after  operation.  Albarran  and  Giordano 
have  each  recorded  cases  well  six  years,  and  Fenwick  a  case  five 
years,  after  operation  in  malignant  growths. 

LITERATURE 

Drew,  Trans.  Path.  Soc,  1897,  p.  130. 

Heresco,   Ann.  d.  Mai.  d.  Org.  Gin.-  Urin.,  1901,  p.  655. 

Legueu,    Traite  Ghirurgical  cZ'  Urologie.     1910. 

Morley,  Lancet,  June  11,  1910. 


CHAPTER  XIV 
CYSTS  OF  THE  KIDNEY 

Apart  from  retention  cysts  of  the  kidney  due  to  obstruction  in 
the  renal  pelvis  (hydronephrosis,  pyonephrosis),  there  are  several 
varieties  of  renal  cysts,  some  of  which  are  of  doubtful  origin. 
These  are  as  follows  : — 

Multiple  cysts  in  chronic  nephritis. 

Dermoid  cysts. 

Polycystic  kidney  and  congenital  cystic  kidney. 

Solitary  cysts  or"  serous  cysts. 

Hydatid  cysts. 
Multiple  cysts  occurring  in  kidneys  the  seat  of  chronic  nephritis 
possess  no  surgical  interest, 

DERMOID   CYSTS 

Dermoid  cysts  of  the  kidney  are  very  rare,  only  6  or  7  examples 
— those  of  Haeckel,  Rider  Thompson,  Madelung,  Walker,  Biggs, 
Wyss,  and  Goldschmidt — being  on  record.  The  cases  of  Haeckel 
and  Rider  Thompson  originated  in  the  neighbourhood  of  the  renal 
pelvis.  Goldschmidt' s  case  was  subcapsular.  In  the  cases  of  Mad- 
elung and  Wyss  the  cysts  were  calcified  and  had  replaced  almost 
the  whole  kidney.  In  a  case  that  came  under  my  observation  the 
patient  had  previously  submitted  to  an  incomplete  operation  of 
which  I  could  obtain  no  details.  There  was  extensive  scarring., 
and  a  long  sinus  leading  to  the  region  of  the  left  kidney.  A  large 
wisp  of  black  hair  and  a  quantity  of  pultaceous  material  were 
removed  from  a  ca^dty  in  this  region.  Some  fragments  of  squamous 
epithelium  were  identified  in  the  scrapings  from  this  cavity.  The 
urine  was  normal,  and  the  bladder  and  ureteric  orifices  healthy. 
The  sinus  closed. 

LITERATURE 

Biggs,  New  York  Path.  Soc.  Tra7is.,vo\.  Ixxxviii. 
Goldsehmidt,  Surg.,   Gyn.,  and  Obst.,  1909,  p.  400. 
Haeckel,  Berl.  klin.   Woch.,  1902,  p.  964. 
Madelung,  Arch.  f.  klin.  Chir.,  1887. 
Thompson,  Rider,  Lancet,  1906,  ii.   1589. 
Williams,  Lancet,  1913,  i.  561. 

207 


208  THE   KIDNEY  [chap. 

POLYCYSTIC   KIDNEY  AND   CONGENITAL   CYSTIC 

KIDNEY 

In  this  condition  the  kidney  is  transformed  into  a  collection 
of  cysts,  and  has  an  appearance  almost  like  a  bunch  of  grapes. 

Etiology. — ^Polycystic  kidney  is  sometimes  found  in  several 
members  of  a  family,  and  there  may  be  an  ancestry  of  the  same 
disease.  In  infants  affected  with  polycystic  kidney  develop- 
mental errors  have  sometimes  been  noted,  such  as  horseshoe 
kidney,  hare-lip,  etc.  The  disease  may  be  present  at  birth,  and 
occurs  in  infants  and  in  adults.  It  is  rarely  found  between  infancy 
and  the  age  of  21.  In  adult  life  it  is  most  common  between  the 
ages  of  40  and  50.  Women  are  more  frequently  affected  than 
men  in  the  ratio  of  7  to  5,  and  the  left  side  is  slightly  more  often 
affected  than  the  right.  The  disease  is  bilateral  in  almost  all 
cases,  being  more  advanced  in  one  kidney.  Lejars  found  that 
only  2  out  of  63  cases  in  adults  were  unilateral,  and  Richie  only 
2  out  of  72  post-mortem  examinations. 

Pathology. — It  is  now  almost  universally  held  that  the  poly- 
cystic kidney  of  infants  (congenital  cystic  kidney)  and  that  of 
adults  are  identical. 

The  kidney  reaches  enormous  proportions  and  may  weigh  .as 
much  as  16  lb.  The  characteristic  outline  of  the  kidney  is  pre- 
served. The  organ  is  converted  into  a  mass  of  cysts  of  varying 
sizes,  some  being  hardly  visible  to  the  naked  eye,  while  others 
are  the  size  of  a  cherry  or  a  grape.  On  the  surface  the  thin  walls 
of  the  cyst  are  semi-transparent,  and  show  the  clear  yellow  or 
brown  within.  On  section  the  cysts  are  spread  throughout  the 
substance  of  the  kidney,  being  especially  numerous  in  the  cortex 
and  at  each  pole.  In  some,  fine  septa  are  found,  suggesting  coales- 
cence of  smaller  to  form  larger  cysts.  The  kidney  tissue  lying 
between  may  be  indistinguishable  with  the  naked  eye. 

The  cysts  contain  a  clear  yellow  or  sometimes  brownish  fluid 
which  holds  in  suspension  cortical  and  columnar  epithelial  cells, 
tube  casts,  red  blood-corpuscles,  leucocytes,  and  sometimes  uric- 
acid  and  calcium  oxalate  crystals.  Urea  is  present  in  small  quan- 
tities, and  albumin,  phosphates,  chlorides,  and  cholesterin  are  also 
constituents. 

I  The  kidney  may  be  movable  and  is  sometimes  displaced.  The 
renal  pelvis  is  often  deformed,  and  the  pyramids  are  transformed 
into  cysts.  Calculi  have  been  found  in  the  pelvis.  There  may 
be  double  ureter,  and  sometimes  small  cysts  are  present  on  the 
mucous  membrane  ;  these  have  also  been  found  in  the  bladder. 
The  wall  of  the  kidney  cysts  is  formed  by  connective  tissue  lined 


XIV]  POLYCYSTIC   KIDNEY  209 

with  columnar  cubical  or  flattened  epithelium,  which  shows  pro- 
liferation in  parts,  and  the  heaping  up  of  epithehum  gives  the 
appearance  of  papillary  formations. 

The  tissue  between  the  cysts  is  fibrous,  and  under  the  micro- 
scope shows  tubules  and  glomeruli  compressed  and  separated  by 
fibrous  tissue.  The  larger  cysts  are  surrounded  by  denser  fibrous 
tissue  than  that  around  the  smaller. 

Cystic  changes  in  the  liver  are  present  in  18  per  cent,  of  cases 
of  polycystic  kidney.  The  liver  cysts  are  due  to  dilatation  of 
biliary  canals.  They  are  not  usually  numerous,  but  occasion- 
ally the  organ  may  be  much  enlarged. 

Cystic  changes  have  also  been  found  in  a  few  cases  in  the  pan- 
creas, spleen,  thyroid  gland,  ovaries,  uterus,  and  seminal  vesicles. 
Hypertrophy  of  the  left  ventricle  of  the  heart  and  arterio-sclerotic 
changes  are  frequently  present. 

Pathogenesis. — The  follo^^dng  theories  have  been  advanced 
to  explain  the  development  of  the  cystic  changes  : — 

1.  Congenital  theory. — The  frequent  occurrence  of  poly- 
cystic kidney  in  the  new-born,  and  of  concomitant  malformations 
such  as  hare-lip,  etc.,  and  the  occasional  appearance  of  the  disease 
in  several  members  of  one  family,  give  support  to  this  theory. 
The  congenital  lesion  has  been  held  to  be — 

{a)  Degeneration  of  remnants  of  the  Wolffian  body. 

(h)  Unusual  feebleness  of  the  tubules  leading  to  dilatation 

by  the  normal  intrarenal  pressure, 
(c)  Failure  of  union  of  the  excretory  canals  with  the  con- 
voluted tubules. 
Huber  has  shown  that  the  excretory  canals  and  convoluted 
tubules   are   developed  from   separate   structures.     In   the   early 
embryo  there  are  a  renal  vesicle  and  a  primary  collecting  tubule, 
which  are  separate  structures,  and  these  become  united  to  form 
a    single    canal,    which   later   becomes    convoluted.     Should   this 
union  fail  to  take  place,  cysts  will  form  from  the  renal  vesicle. 
It  is  significant  that  the  early  stage  of  polycystic  disease  is  found 
in  the  cortex  of  the  kidney,  where  these  developmental  changes 
take  place.     This  is  the  most  probable  of  the  congenital  theories. 

2.  Inflammation  theory. — Virchow  held  that  the  cysts  re- 
sult from  occlusion  of  the  urinary  tubules,  caused  by  inflam- 
mation of  the  interstitial  tissue  in  the  papilla  of  the  kidney. 
Inflammation  of  the  papilla  is,  however,  seldom  found,  and  experi- 
mental e\ddence  shows  that  artificial  papillitis  is  not  followed  by 
the  development  of  cystic  kidney. 

The  presence  of  interstitial  nephritis  has  been  held  to  sup- 
port this  theory.     It  is  generally  beheved,  however,  that  this  is 
o 


210  THE   KIDNEY  [chap. 

the  result,  and  not  the  cause,  of  the  cystic  formation,  a  view  which 
is  supported  by  the  greater  density  of  the  sclerosis  round  the 
larger  than  round  the  smaller  cysts. 

3.  Neoplastic  theory. — This  theory  is  supported  partly  by 
analogy  with  cystic  tumours  elsewhere,  and  also  by  certain  his- 
tological characters.  There  is  excessive  proliferation  of  the  cells 
lining  the  cysts,  and  nuclear  division  is  abundant.  The  tubules 
may  be  filled  with  young  cells,  and  there  are  papillary  ingrowths 
into  the  cysts.  Transition  stages  'between  the  solid  masses  of 
epithehal  cells  and  the  cysts  are  stated  to  exist. 

At  the  present  time  the  weight  of  opinion  appears  to  favour 
the  congenital  and  neoplastic  theories. 

Symptoms. — The  congenital  form  may  give  rise  to  dijB&cult 
labour,  on  account  of  the  size  of  the  kidney  or  liver.  The  large 
size  of  the  infant's  abdomen  attracts  attention  at  birth  and  leads 
to  discovery  of  the  tumour.  Death  from  uraemia  takes  place 
soon  after  birth. 

The  course  of  symptoms  of  polycystic  kidney  in  the  adult  may 
be  described  in  three  periods  : 

1.  Latent  period. 

2.  Period  of  renal  tumour  with  symptoms. 

3.  Period  of  renal  failure. 

1.  The  disease  may  remain  latent  or  undiscovered  mitil  the 
kidney  has  attained  a  large  size.  The  duration  of  this  stage  is 
difficult  to  estimate,  but  it  may  be  several  years, 

2.  This  period  commences  with  the  discovery  of  the  enlarged 
kidney  and  the  development  of  symptoms. 

Tumour. — ^Although  the  disease  is  almost  always  bilateral,  it 
is  more  advanced  in  one  kidney.  In  most  cases,  therefore  (76  per 
cent.),  the  tumour  is  clinically  unilateral. 

The  tumour  may  be  of  very  large  size.  It  has  the  position, 
contour,  and  percussion  note  of  a  renal  tumour.  In  very  thin 
subjects  surface  cysts  may  be  recognized  on  palpation.  The 
kidney  is  sometimes  displaced  or  unduly  movable.  It  is  occasion- 
ally tender.  Pain  is  present,  but  may  be  late  in  onset.  It  is  a 
dull  aching  in  the  loin,  and  there  may  be  attacks  of  ureteric  colic 
due  to  the  passage  of  clots. 

Changes  in  the  urine  are  constant.  There  may  be  polyuria, 
amounting  to  as  much  as  17|  pints  in  twenty-four  hours.  The  poly- 
uria may  be  interrupted  by  periods  of  oHguria,  or  even  anuria. 
The  specific  gravity  is  low,  and  there  is  frequently,  but  not  inevit- 
ably, a  trace  of  albumin.  Casts  are  rarely  found.  The  quantities 
of  urea  and  urinary  salts  are  diminished.  Haematuria  occurs  in 
16  per  cent,  of  cases  (Luzzato),  and  is  intermittent  and  slight. 


XIV]  POLYCYSTIC   KIDNEY  211 

The  heart  is  hypertrophied  and  the  arteries  are  sclerosed. 
(Edema  of  the  feet,  but  not  of  the  eyehds,  occurs,  and  there  is  no 
ascites.     Pressure  upon  the  bowel  produces  constipation. 

3.  In  the  period  of  renal  failure  the  urine  becomes  scanty, 
anuria  supervenes,  and  symptoms  of  uraemia  develop. 

The  patient  is  drowsy  and  suffers  from  severe  headaches,  dys- 
pepsia, vomiting,  and  diarrhoea.  The  face  is  pale,  sometimes 
bronzed,  and  the  body  emaciated.  Convulsions  occur,  and  the 
patient  dies  comatose. 

Diagnosis. — When  the  tumour  is  bilateral  and  there  are  signs 
of  chronic  nephritis  the  diagnosis  is  easily  made.  When  the 
tumour  is  unilateral  the  diagnosis  is  difficult.  Hydronephrosis  is 
excluded  by  the  variation  in  size  of  the  hydronephrotic  tumour 
with  catheterization  of  the  ureter.  A  diagnosis  of  new  growth  of 
the  kidney  will  probably  be  made,  but  it  is  impossible  to  differen- 
tiate between  cancer,  pararenal  tumour,  hydatid  cyst,  and  poly- 
cystic kidney,  unless  a  history  of  several  years'  duration,  char- 
acteristic of  polycystic  kidney,  can  be  obtained. 

Prognosis. — The  disease  is  invariably  fatal,  but  the  duration 
may  extend  over  many  years.  Jossaud  found  that  the  age  at 
death  in  47  cases  was  between  50  and  60,  in  17  cases  between 
60  and  70,  in  11  between  70  and  80,  and  in  2  between  80 
and  90. 

Treatment. — The  disease  has  been  shown  to  be  bilateral  in 
all  but  the  rarest  cases,  and  nephrectomy  is  contra-indicated  on 
this  account.  After  nephrectomy  the  disease  of  the  second  kidney 
continues  to  develop,  and  the  patient  dies  of  renal  failure.  In 
polycystic  kidney  more  than  in  any  other  disease  of  the  kidney 
the  period  of  existence  of  the  patient  is  measured  by  the  amount 
of  active  renal  tissue,  and  the  removal  of  a  portion  of  this  by 
nephrectomy  can  only  be  called  for  under  the  most  exceptional 
conditions  of  severe  pain  or  violent  heematuria.  The  mortality 
of  nephrectomy  in  60  cases  collected  by  Seiber  was  32-7  per  cent 
The  longest  survivals  were  4  after  three  years,  1  after  five  years, 
1  after  six  years,  and  2  after  seven  years. 

Nephrotomy  with  evacuation  of  the  large  cysts  has  been  per- 
formed for  pain,  and  may  be  tried  in  anuria. 

LITERATURE 

Huber,  Amer.  Journ.  of  Anat.,  Supplement,  1904-5,  p.  17. 

Lejars,  These  cle  Paris,  1888. 

Luzzato,  La  Degenerazione  cistica  del  Rein.     Venice,  1900. 

Malassez,  Bull.  Soc.   Aimt.,  1877,  p.  566. 

Ritchie,  Lah.  Repts.  Roy.  Coll.  Phys.  Edin.,  1892,  p.  213. 

Seiber,  Deuts.  Zeits.  f.  Chir.,  1905,  p.  495. 

Stromberg,  Folia  Urol.,  1909,  p.  541. 


212 


THE  KIDNEY 


[chap. 


SOLITAEY     CYSTS 

Large  single  cysts  of  the  kidney  are  very  rare.  They  have  also 
been  termed  "  serous  "  cysts — a  misnomer,  as  in  some  cases  urinary 
constituents  have  been  found  in  the  fluid  contents. 

Guinsberg  in  1903  could  only  find  39  cases  recorded  in  the 
literature.  They  are  rarely  (7  cases)  bilateral,  and  each  kidney  is 
affected  with  equal  frequency. 

Pathology. — The  cyst  may  be  found  at  the  upper  or  the 
lower  pole,  or  in  the  body  of  the  organ,  and  may  arise  in  the  cortex 


\ 


Fig.  55.  —  Large  cyst  and 
multiple  small  cysts  of 
the  kidney,  with  adeno- 
carcinomatous  growth. 


or  the  medulla.  There  is  usually  one  cyst,  but  rarely  two  or  three 
are  present.  It  is  usually  the  size  of  a  fist  or  of  an  orange,  but 
may  be  larger.  A  cyst  observed  by  Morris  weighed,  with  its  con- 
tents, 16  lb.,  and  measured  29  by  26  in.  in  diameter. 

The  cyst  projects  from  the  surface  of  the  kidney,  and  its  wall 
consists  of  a  thin,  transparent,  fibrous  membrane  in  which  vessels 
course.  The  interior  frequently  shows  the  remains  of  septa  in- 
dicating the  fusion  of  smaller  cysts  to  form  a  single  large  cyst. 
Occasionally  the  wall  is  thick  and  very  hard.  It  has  an  incom- 
plete lining  of  flattened  or  cubical  epithelial  cells.    At  the  margin 


XIV]  SOLITARY  CYSTS  213 

of  attachment  to  the  kidney  a  thin  layer  of  kidney  tissue  passes 
for  a  short  distance  on  to  the  cyst  wall.  Except  in  very  rare  cases, 
the  cyst  does  not  communicate  with  the  pelvis  or  the  calyces. 
The  cavity  contains  clear  fluid,  amber  or  yellow,  in  which  albumin, 
chlorides,  phosphates,  and  traces  of  urea  are  found.  Sometimes 
blood  is  mixed  with  the  fluid. 

The  parenchyma  of  the  kidney  in  the  immediate  vicinity  of 
the  cyst  is  compressed  and  fibrous,  but  the  rest  of  the  kidney  is 
normal. 

Cysts  in  all  respects  similar  to  these  are  found  along  with 
numerous  small  cysts  in  kidneys  which  are  the  seat  of  chronic 
interstitial  nephritis.  Fig.  55  is  taken  from  a  kidney  re- 
moved post  mortem  from  a  man,  aged  65,  who  had  suffered 
from  enlarged  prostate.  The  kidney  was  moderately  dilated  and 
showed  chronic  interstitial  nephritis  with  numerous  small  and  one 
large  cyst  and  an  adeno-carcinomatous  growth  the  size  of  a 
marble. 

A  calculus  has  been  found  in  a  solitary  cyst  (Roche). 

Pathogenesis. — The  cysts  are  generally  held  to  be  retention 
cysts,  although  the  ultimate  cause  is  not  clear.  The  fact  that 
large  cysts  indistinguishable  from  these  solitary  cysts  are  some 
times  found  in  sclerosed  kidneys,  and  the  more  frequent  occur- 
rence of  small  cysts  in  these  kidneys,  point  to  sclerosis  as  the 
initial  lesion. 

Brigidi  and  Seven  hold  that  the  cysts  arise  from  the  glomeruli 
or  tubules  and  are  due  to  obstruction  caused  by  desquamated 
and  degenerated  cells,  sometimes  mixed  with  blood. 

Symptoms  and  diagnosis. — Small  cysts  and  even  compara- 
tively large  cysts  are  unrecognized  during  life,  and  are  found  at 
autopsy. 

Large  cysts  may  give  rise  to  pressure  symptoms.  There  is 
frequently  dull,  aching,  heavy  pain  in  the  loin.  Recamier  records 
a  case  in  which  there  was  sudden  severe  lumbar  pain  and  vesical 
tenesmus  caused  by  a  large  cyst  at  the  upper  pole  of  the  kidney. 
(Edema  of  the  lower  extremities  may  be  produced  by  pressure  on 
veins,  and  the  intestine  may  be  compressed  by  a  large  cyst.  The 
urine  shows  no  change. 

Large  cysts  are  very  difficult  to  recognize  as  originating  in  the 
kidney,  and  are  frequently  mistaken  for  ovarian  cysts.  Smaller 
cysts  are  more  easily  diagnosed  as  belonging  to  the  kidney.  They 
possess  the  characters  of  a  renal  tumour.  Of  renal  tumours  they 
are  most  likely  to  be  mistaken  for  hydronephrosis  or  new  growth, 
as  thev  may  form  symptomless  renal  tumours.  The  fixed  volume, 
the  failure  of  catheterization  of  the  ureter  to  empty  the  tumour, 


214  THE   KIDNEY  [chap. 

and  the  injection  of  collargol  (pyelography)  into  the  renal  pelvis 
show  that  the  kidney  is  not  dilated. 

Of  52  cases  collected  by  Simon  the  correct  diagnosis  was  only 
made  in  4.  The  most  frequent  mistakes  in  diagnosis  were  ovarian 
cyst  (9),  movable  kidney  (5),  renal  growth  (5),  cyst  of  liver  (4), 
and  hydronephrosis  (2). 

Prognosis. — The  cysts  are  benign  and  unilateral.  By  con- 
tinued increase  the  kidney  may  be  destroyed  by  compression. 
Suppuration  may  in  rare  instances  occur. 

Treatment. — After  exposure  of  the  kidney  by  the  lumbar 
route  the  cyst  may  be  incised  and  the  wall  brought  up  to  the 
surface  and  stitched  to  the  skin.  A  permanent  fistula  occurs  in 
50  per  cent,  of  cases  treated  in  this  way. 

Resection  of  the  pouch  should  be  carried  out  whenever  pos- 
sible. The  part  which  projects  beyond  the  kidney  surface  should 
be  cut  away,  and  the  remaining  portion  of  cyst  wall  in  the  sub- 
stance of  the  kidney  cauterized.  This  part  cannot  be  dissected 
from  the  kidney  without  lacerating  the  kidney  tissue  and  causing 
free  haemorrhage. 

Partial  nephrectomy  consists  in  removing  the  part  of  the  kidney 
containing  the  cyst.  This  can  be  performed  when  the  cyst  is 
situated  at  one  pole,  and  if  the  renal  pelvis  is  not  opened  the 
wound  heals  without  a  fistula.  The  results  of  this  operation  are 
good.  Simon  collected  10  cases  of  partial  nephrectomy  with 
10  recoveries. 

Nephrectomy  is  the  usual  treatment  for  large  cysts.  The 
results  have  recently  much  improved.  In  1891  Tuffier  found  a 
mortality  of  45  per  cent.  (11  in  24),  while  in  1903  Albarran  found 
7  cases  of  nephrectomy  with  7  recoveries. 

In  large  cysts  the  diagnosis  will  probably  be  doubtful  and 
the  transperitoneal  route  undertaken.  In  small  cysts  the  kidney 
is  approached  by  the  lumbar  route. 

LITERATUEE 

Guinsberg,  These  de  Paris,  1903. 

Morris,  Surgical  Diseases  of  the  Kidney  and  Ureter,  i.  634.     1901. 

Roche,  Ann.  d.  Mai.  d.  Org.   Gen.-  Urin.,  1895,  p.  1139. 

HYDATID   CYSTS 

Hydatid  cysts  represent  the  cysticercus  stage  of  the  taenia 
echinococcus,  a  cestode  which  inhabits  the  upper  part  of  the 
intestinal  tract  of  certain  animals,  notably  the  dog,  sheep,  ox, 
and  pig. 

The  method  of  conveyance  of  the  ova  to  the  human  being  is 
as  follows :    The  proglottis  is  shed  and  discharged  with  the  faeces 


XIV]  HYDATID   CYSTS  215 

of  the  dog  or  other  auiinal.     The  ova  are  then  deposited  on  grass, 
vegetables,  and  in  water,  and  may  remain  viable  for  a  long  time, 
even   in   the   dry   state.     Uncooked   vegetables,    such   as   lettuce, 
parsley,  or  watercress,  are  most  likely  to  convey  the  ova  to  the 
human  intestinal  tract,  or  dogs  may  convey  the  ova  by  licking 
the  face  or  hands.     The  latter  is  not,  however,  a  frequent  form 
of  contagion,  for  children  are  most  likely  to  submit  to  this  demon- 
stration of  aii'ection,  and  they  are  very  rarely  affected  with  hydatid 
disease.     On  reaching  the  stomach  the  envelope  which  surrounds 
the  egg  is  dissolved,  and  the  embryo,  by  means  of  six  small  hook- 
lets,  becomes  attached  to  and  penetrates  the  mucous  membrane, 
entering  either  the  blood  or  the  lymphatic  stream.     It  is  arrested 
in  the  capillaries  of  the  liver  in  the  majority  of  cases,  but  may  be 
deposited  in  any  part  of  the  body.     The  kidney  is  affected  in  a 
very  small  proportion  of  cases.     Thomas  found  only  2  renal  cases 
in  307  cases  of  hydatid  disease  (0-065  per  cent.)  in  Australia,  and 
Cranwell  and  Vegas  found  36  renal  cases  in  1,696  in  Buenos  Ayres 
(0-021  per  cent.).     When  the  embryo  becomes  arrested  in  a  capil- 
lary vessel   development   of  the  hydatid  cyst   commences.     The 
booklets  disappear,  and  a  small  cyst  slowly  forms,  the  wall  of 
which  consists  of  two  layers,  an  outer  fibrous  and  an  inner  ger- 
minal layer.     Outside  the  cyst  wall  the  reaction  of  the  tissues 
forms  a  fibrous  layer  called  the  ectocyst.     On  the  inside  of  the 
germinal  layer  groups  of  small  vesicles  called  brood  capsules  are 
formed  on  narrow  pedicles.     Inside  the  brood  capsules   scolices 
are  formed.     The  scolex  is  less  than  a  pin-head  in  size,  and  is  pro- 
vided with  booklets  and  four  sucking  discs.     These  booklets  may 
become  diffused  in  the  fluid  of  the  hydatid  cyst.     In  addition  to 
these  scolices,  daughter  cysts  resembling  the  parent  cyst  in  every 
particular  develop  from  the  cyst  wall,  and  may  grow  outwards 
or  inwards  into  the  cavity  of  the  cyst.     The  daughter  cysts  become 
detached  and  may  fill  the  parent  cyst.     They  vary  in  size  from 
a  pea  to  a  gooseberry. 

The  fluid  contained  in  an  hydatid  cyst  is  opalescent,  it  has 
a  specific  gravity  of  1005  to  1015,  and  contains  albumin,  sodium 
chloride,  phosphates,  sodium  sulphate,  succinic  acid,  and  certain 
toxic  bodies  of  unknown  nature. 

Etiology. — Hydatid  disease  is  prevalent  in  some  countries 
and  rare  in  others.  In  Iceland,  Australia,  and  the  Argentine 
Republic  it  is  common ;  in  Germany,  Russia,  Austria,  and  France 
it  is  less  common ;  in  Great  Britain  and  Ireland  it  is  uncommon, 
and  in  the  United  States  and  Canada  it  is  rare.  In  this  geographical 
distribution  it  is  noticeable  that  dogs  are  proportionally  most 
numerous  and  live  in  most  intimate  relationship  to  human  beings 


216  THE  KIDNEY  [chap. 

in  Iceland.  The  disease  occurs  most  frequently  between  the  ages 
of  20  and  40  ;  it  is  very  rare  under  the  age  of  15.  Men  and  women 
are  affected  in  about  equal  numbers,  and  the  right  kidney  as  often 
as  the  left. 

Trauma  appears  to  have  some  influence  in  localizing  the  deposit 
of  the  hydatid  embryo.     Multiple  hydatid  cysts  are  very  rare. 

Pathology. — The  embryo  is  arrested  in  the  capillary  plexus 
of  the  convoluted  tubules,  usually  at  one  pole  of  the  kidney.  Rarely 
the  cyst  develops  at  the  hilum.  The  growth  is  slow,  but  after 
reaching  the  size  of  the  fist  the  cyst  may  increase  rapidly  to  a 
large  size. 

In  the  neighbourhood  of  the  cyst  the  kidney  tissue  is  com- 
pressed and  sclerosed ;  rarely  a  large  part  of  the  kidney  tissue 
is  destroyed  by  pressure.  As  the  cyst  develops  it  projects  from 
the  surface  of  the  kidney  and  forms  adhesions  with  the  neigh- 
bouring structures  and  organs. 

The  cyst  may  continue  to  grow  for  twenty  years  or  more,  giving 
rise  to  pressure  or  other  symptoms. 

Active  growth  sometimes  ceases  and  the  cyst  dies.  When 
this  occurs  the  cyst  shrinks,  its  walls  become  calcified,  the  fluid 
is  gradually  absorbed,  and  the  contents  of  the  cyst  are  converted 
into  a  putty-like  mass.  A  large  cyst  may  rupture.  This  most 
frequently  takes  place  into  the  pelvis  of  the  kidney,  and  the  con- 
tents are  discharged  down  the  ureter,  the  daughter  cysts  being 
passed  in  the  urine.  The  cyst  may  now  collapse  and  give  no 
further  trouble ;  more  commonly,  however,  it  fills  up  again,  and 
the  rupture  is  repeated  after  an  interval  of  some  years. 

Rupture  of  the  cyst  into  the  stomach,  the  bowel,  or  the  lung 
may  take  place.  Rarely  the  contents  are  discharged  into  the 
peritoneal  cavity. 

Suppuration  of  the  cyst  without  rupture  is  very  exceptional ; 
it  frequently  follows  rupture,  and  is  a  grave  complication. 

Symptoms. — The  first  intimation  is  the  discovery  of  a  pain- 
less tumour  in  the  lumbar  region.  The  tumour  is  globular  and 
occupies  the  position  of  the  kidney.  In  a  favourable  subject  the 
kidney  may  be  detected  attached  to  the  tumour.  There  is  no 
movement  with  respiration.  Percussion  shows  a  resonant  band 
on  the  anterior  surface  of  the  tumour  if  the  cyst  is  of  moderate 
size,  but  in  large  cysts  the  colon  is  pushed  aside  and  the  note  is 
dull.  Fluctuation  can  seldom  be  detected.  A  tensely  filled  cyst 
is  hard  like  a  soUd  tumour.  A  hydatid  thrill  can  be  elicited  in  a 
small  number  of  cases  (2  in  30 — Houzel).  It  is  obtained  by  placing 
one  hand  flat  on  the  tumour  and  tapping  it  sharply  with  the  other. 
A  sensation  of  weight  and  discomfort  in  the  lumbar  region  is 


XIV]  HYDATID   CYSTS  217 

common.  In  large  tumours  there  may  be  pain  caused  by  dragging 
on  adhesions  or  by  pressure  upon  nerves. 

Severe  colic  along  the  line  of  the  ureter  occurs  when  the  cyst 
ruptures  into  the  renal  pelvis  and  the  daughter  cysts  are  dis- 
charged into  the  bladder.  The  urine  is  normal  except  where 
rupture  into  the  renal  pelvis  has  occurred. 

Rupture  into  the  renal  pelvis  occurs  very  frequently  (104  out 
of  161  cases — Nicaise).  It  is  accompanied  by  severe  pain  in  the 
region  of  the  kidney,  and  colic  along  the  line  of  the  ureter.  There 
are  vomiting  and  collapse.  The  urine  becomes  turbid  and  alkaline 
and  contains  small  hydatid  cysts,  complete  or  ruptured,  scoHces, 
booklets,  fat  droplets,  and  sometimes  blood.  There  may  be  diffi- 
culty in  passing  the  cysts  through  the  urethra,  causing  frequent 
mictmition,  straining,  and  sometimes  retention  of  urine.  These 
symptoms  may  continue  intermittently  for  several  days,  and  then 
cease.  Sometimes  the  cyst  is  completely  emptied  and  sponta- 
neous cure  is  established;  usually,  however,  the  cyst  refills,  and 
recurrence  of  the  rupture  and  its  attendant  symptoms  takes 
place  after  a  year  or  more.  Boeckel  found  that  6  cases  out  of  29 
recovered  after  rupture  into  the  renal  pelvis.  More  frequently 
inflammation  with  suppuration  follows  the  rupture.  Rupture  may 
also  take  place  into  the  stomach  or  intestine,  with  subsequent 
suppuration  of  the  sac. 

Rupture  into  the  peritoneal  cavity  is  usually  the  result  of 
external  violence.  Acute  peritonitis  may  immediately  result  and 
prove  fatal,  or  a  more  chronic  form  of  peritonitis  may  supervene. 
Multiple  secondary  cysts  are  sometimes  formed  in  the  peritoneum, 
arising  directly  from  scolices  which  have  been  disseminated. 
Rupture  of  a  hydatid  may  be  followed  by  symptoms  of  toxaemia 
which  are  believed  to  result  from  the  absorption  of  toxins  con- 
tained in  the  hydatid- fluid.  The  temperature  is  high,  and  there 
is  general  urticaria.     In  severe  cases  there  are  convulsions. 

Suppuration  in  the  hydatid  cyst  occurs  after  rupture  into  the 
pelvis  or  elsewhere. 

Diagnosis. — The  diagnosis  is  that  of  other  renal  tumours.  When 
the  tumour  is  small  the  diagnosis  is  easily  made,  but  with  large 
tumours  it  may  be  extremely  difficult. 

When  the  tumour  has  been  localized  to  the  kidney,  the  differ- 
ential diagnosis  from  a  soHd  growth  or  from  other  cystic  conditions 
of  the  kidney  is  also  attended  with  great  difficulty.  The  hydatid 
tumour  is  of  very  slow  growth,  and  is  unaccompanied  by  attacks 
of  pain,  nor  does  it  show  variations  in  size  or  changes  in  the 
urine,  which  would  point  to  hydronephrosis.  Catheterization  of  the 
ureters  and  pyelography  fm'ther  exclude  dilatation  of  the  kidney. 


218  THE   KIDNEY  [chap. 

From  polycystic  kidney  or  a  large  solitary  cyst  the  diagnosis 
is  more  difficult.  Polycystic  kidney  may  be  bilateral  clinically, 
wliile  hydatid  and  solitary  cysts  are  unilateral.  The  patient  may 
have  been  exposed  to  contagion,  a  hydatid  thrill  may  be  detected, 
and,  if  the  cyst  has  ruptured  into  the  renal  pelvis,  cysts  and 
booklets  are  found  in  the  urine. 

The  blood  in  cases  of  hydatid  cyst  may  show  an  eosinophiha 
amounting  to  40  per  cent. 

Recently  the  reaction  known  as  "  fixation  of  the  complement  " 
has  been  employed  for  the  diagnosis  of  hydatid  cysts,  and  has 
given  important  results. 

Course  and  prognosis. — The  disease  may  last  for  twenty 
years  or  more,  giving  rise  only  to  symptoms  of  pressure  on  neigh- 
bouring organs.  Spontaneous  cure  occurs  rarely.  The  slow 
destruction  of  renal  tissue  is  compensated  by  hypertrophy  of  the 
second  kidney,  and  does  not  affect  the  prognosis  unless,  as  has 
exceptionally  occurred,  the  hydatid  cyst  develops  in  a  solitary 
kidney. 

Suppuration  of  the  cyst  and  rupture  are  serious  and  often  fatal 
complications. 

Treatment. — Only  operative  measures  need  be  considered. 

Nephrectomy. — This  should  only  be  performed  when  it  is 
impossible  to  adopt  more  conservative  measures.  The  cases 
suitable  for  nephrectomy  are  those  in  which  the  kidney  is  totally 
or  almost  totally  destroyed  by  a  large  cyst,  and  those  in  which 
the  cyst  develops  in  the  hilum  of  the  kidney,  involving  the  renal 
vessels  and  making  the  removal  of  the  cyst  alone  a  more  danger- 
ous proceeding  than  nephrectomy.  Where  suppuration  of  the 
cyst  has  extended  to  the  kidney,  nephrectomy  may  be  advisable ; 
and  where  the  cyst  has  ruptured  into  the  intestine,  peritoneum, 
or  lung,  the  kidney  should  be  removed. 

The  operation  may  be  rendered  extremely  difficult  by  wide- 
spread adhesions,  and  it  is  sometimes  wiser,  on  account  of  the 
danger  of  haemorrhage,  to  be  content  with  less  radical  measures. 

In  42  nephrectomies  Nicaise  found  a  mortality  of  19  per  cent, 
due  to  the  operation.  Lumbar  nephrectomy  was  less  fatal  than 
transperitoneal. 

Resection,  or  partial  "nephrectomy. — This  operation  is 
applicable  only  in  small  cysts  situate  at  the  poles  or  on  the 
convex  border.  The  kidney  is  exposed  by  a  lumbar  incision,  the 
renal  vessels  are  controlled  by  pressure,  and  the  kidney  is  incised 
immediately  outside  the  ectocyst,  cutting  through  kidney  tissue. 

When  the  cyst  has  been  removed  the  raw  surfaces  are  stitched 
together  with  catgut.     Nicaise  collected  14  cases  with  3  deaths. 


XIV]  HYDATID   CYSTS  219 

Nephrostomy,  or  marsupialization. — The  cyst  is  exposed 
by  a  lumbar  incision,  and  part  of  the  fluid  is  aspirated  so  that 
the  flaccid  wall  of  the  cyst  can  be  drawn  through  the  wound.  The 
cyst  is  opened  and  washed  out,  and  as  much  as  possible  of  the 
wall  clipped  away.  The  edges  are  then  sutured  to  the  skin  and 
a  drain  introduced.  The  pouch  is  washed  out  daily  with  iodine 
or  other  antiseptic  solution.  The  drain  should  be  removed  about 
the  fourth  day,  and  the  wound  allowed  to  heal.  The  mortality 
of  this  operation,  according  to  Nicaise,  is  6-12  per  cent. 

In  order  to  minimize  the  risk  of  suppuration  after  an  opera- 
tion such  as  nephrostomy,  Delbet  suggests  that  as  much  as  pos- 
sible of  the  cyst  wall  shoidd  be  removed  and  the  opposing  surfaces 
stitched  together  with  catgut.  The  edges  of  the  ectocyst  are  then 
brought  together  and  sutured. 

LITEEATURE 

Boeckel,  £tude  sur  les  Kystes  Hydatiques  du  Rein.  Paris,  1887. 
Cranwell  and  Vegas,  Revista  de  la  Sociedad  Medica  Argentina,  1904, 
Finsen,  Arch.  Gen.  de  Med.,  1869,  i.  29.  [xii.  215. 

Gardner,  Intercolon.  Quart.  Journ.  Med.  and  Surg.,  1894-5,  i.  147. 
Houzel,  Rev.  de  Chir.,  1898,  xviii.  703. 
Kermisse,  Arch.  Gen.  de  Med.,  1883,  ii.  516. 
Marchat,  These  de  Paris,  1901. 
Nicaise,  These  de  Paris,  1905. 
Thomas,  Lancet,  1879,  i.  297. 


CHAPTER  XV 
PERIRENAL  AND  SUPRARENAL  TUMOURS 

PERIRENAL   TUMOURS 

These  tumours  are  of  rare  occurrence,  but  they  present  a  very 
large  variety  of  structure.  Many  of  them  are  tumours  developing 
in  the  retroperitoneal  tissue,  and  their  relation  to  the  kidney  is 
accidental.  Others  develop  from  vestigial  remains  around  the 
kidney,  and  some  arise  in  the  kidney  capsule. 

Pathology. — The  tumours  are  solid  or  cystic.  Of  the  solid 
tumours,  the  varieties  of  lipoma  are  most  frequently  observed. 
These  are  pure  lipoma,  fibro-lipoma,  myxo-lipoma,  fibro-myxo- 
lipoma.  There  are  also  fibroma  and  fibro-myoma  developing  in 
relation  to  the  fibrous  capsule  of  the  kidney,  which  contains  non- 
striped  muscle  fibres.  These  tumours  are  usually  small,  but  in 
rare  cases  attain  a  large  size. 

Fig.  56  is  drawn  from  a  large  fibro-myoma  or  leio-myoma 
which  I  removed  together  with  the  kidney  from  a  woman  aged  56. 
The  tumour  springs  from  the  tissues  in  the  hilum  of  the  left  kidney. 
The  patient  was  alive  and  well  three  years  after  the  operation. 

Sarcoma  occurs  as  pure  sarcoma  or  fibro-sarcoma,  angio- 
sarcoma, and  some  other  varieties.  The  sarcomas  early  form 
adhesions  with  neighbouring  structures. 

Mixed  tumours  are  rare,  only  a  few  cases  being  on  record. 
The  structure  resembles  that  of  mixed  tumours  of  the  kidney. 
They  arise  in  remains  of  the  Wolffian  body. 

Cysts  may  be  unilocular  or  multilocular.  Unilocular  cysts 
contain  clear  yellow  fluid,  in  which  urea  and  uric  acid  are  some- 
times found.  A  cyst  communicating  with  the  renal  pelvis  has 
been  observed.  Polycystic  tumours  have  been  described.  The 
cystic  tumours  are  beheved  to  arise  in  the  remains  of  the  Wolffian 
body,  or,  according  to  Rambaud,  in  detached  portions  of  the 
embryonic  peritoneum  which  have  become  included  in  the  peri- 
renal tissues. 

Perirenal  tumours  may  acquire  a  large  volume.  When  they 
arise  from  the  fibrous  capsule  of  the  kidney  they  are  firmly  adherent 

220 


CHAr.   XV] 


PERIRENAL  TUMOURS 


221 


to  the  kidney.  Those  originating  in  the  fatty  capsule  are  not 
adherent  to  the  kidney,  but  the  organ  is  buried  in  the  growth. 
Atrophy  of  the  kidney  from  pressure  and  obstruction  of  the  ureter 
may  occur.  Cysts  rarely  form  adhesions  to  surrounding  struc- 
tures, but  sarcomas  and  fibromas  become  early  and  densely 
adherent  to  the  peritoneum  and  intestine.  Necrosis  with  false 
cyst  formation,  fatty  degeneration,  and  calcification  may  take 
place  in  the  solid  tumours.     The  colon  is  pushed  forwards  by  the 


Fig.  56. — Fibro-myoma  arising  from  hilum  of  kidney. 
Operation  specimen. 

growth,  the  bulk  of  which  may  be  either  internal  or  external  to 
the  large  bowel. 

Symptoms. — Tumour  is  the  only  constant  symptom.  It  is 
of  very  slow  growth  in  all  except  the  sarcomas.  Situated  in  the 
loin,  the  tumour  has  the  colon  in  front  of  it.  The  contour  is 
irregular.  The  consistence  depends  upon  the  nature  of  the  growth. 
Fibromas  are  hard,  while  lipomas  are  soft  and  frequently  give  a 
sensation  of  fluctuation. 

Pain  may  be  present,  but  is  inconstant.  Constipation  results 
from  pressure  on  the  colon,  and  oedema,  ascites,  and  varicocele 
from  pressure  on  veins. 

The  urine  is  normal  unless  nephritis  be  present  as  a  compli- 
cation. 


222  THE   KIDNEY  [chap. 

Diagfnosis. — The  slow,  painless  growth  and  the  position  in  the 
loin  and  relation  to  the  colon,  together  with  the  absence  of  urinary 
symptoms,  are  the  points  on  which  the  diagnosis  rests. 

The  nature  of  the  growth  cannot  be  diagnosed,  with  the  ex- 
ception of  sarcoma,  which  is  of  extremely  rapid  growth. 

The  growths  are  most  likely  to  be  mistaken  for  malignant 
tumours  of  the  kidney  or  suprarenal  gland,  hydronephrosis,  ovarian 
tumours,  or  tumours  of  the  liver,  mesentery,  or  pancreas. 

Treatment. — The  growth  should  be  removed  in  the  early 
stage  before  it  has  reached  a  large  size  and  formed  extensive 
adhesions.  In  smaller  growths  the  lumbar  route  should  be 
chosen ;  in  those  of  larger  size  a  transperitoneal  operation  is 
necessary. 

In  the  latter  operation  the  surgeon  exposes  the  tumour  by 
incising  the  peritoneum  on  the  outer  side  of  the  colon,  so  that 
there  is  no  interference  with  the  blood  supply  of  this  part  of  the 
bowel.  The  colon  is  then  dissected  inwards  off  the  growth.  The 
tumour  is  usually  limited  by  the  perirenal  fascia,  and  the  dis- 
section is  more  easily  carried  on  within  this.  The  chief  danger 
is  haemorrhage,  which  may  result  from  injury  to  the  renal  vessels, 
the  spermatic  vessels,  or  the  superior  or  inferior  mesenteric  vessels, 
all  of  which,  at  some  part  of  their  course,  he  within  the  perirenal 
fascia.  The  growth  is  most  readily  attacked  from  the  lower  end, 
which  is  less  vascular,  while  its  relations  are  less  complicated. 
Portions  of  the  growth  may  be  removed  to  allow  of  easier  dis- 
section of  the  remainder.  The  kidney  should  be  isolated  and, 
if  possible,  saved.  In  any  case  the  renal  vessels  should  be  identi- 
fied as  soon  as  possible.  In  the  majority  of  cases  it  is  found 
necessary  to  remove  the  kidney  (66  per  cent. — ^Hartmarm  and 
Lecene). . 

Sarcoma  and  fibroma  form  dense  adhesions;  on  this  account 
they  are  more  difficult  to  remove  than  cysts,  which  shell  out  with 
greater  facility. 

The  mortahty  of  the  operation  has  been  reduced  in  opera- 
tions performed  since  1890  to  6  per  cent.  The  after-results  depend 
upon  the  nature  of  the  growth.  Pure  lipomas,  fibromas,  and  cysts 
do  not  recur,  but  mixed  tumours  and  sarcomas  recur  within  a 
short  time. 

LITERATURE 

Adler,  Bed.  klin.  Woch.,  March  20,  1893. 

Albarran  et  Imbert,  Les  Ttimeurs  du  Rein.     Paris,  1902. 

Bork,  Arch.  /.  klin.  Chir.,  1901,  p.  928. 

Hartmann  et  Lecene,  Travaux  de  Chir.  Anat.  Clin.,  Paris,  1903. 

Rambaud,  These  de  Toulouse,  1903. 


IV.r/fCENTCN  Sr 


Hypernephroma  of  suprarenal    capsule    invading   kidney ;    operation 
specimen.      (P.  223.) 


Plate  12. 


XV]  ADRENAL  TUMOURS  223 

TUMOUES  OF   THE   SUPRARENAL   GLAND 

Growths  arising  in  the  suprarenal  gland  are  rare,  and  are 
slightly  more  frequent  in  the  adult  male  than  in  the  female. 

The  nomenclature  of  these  tumours  is  in  a  state  of  confusion. 
For  the  purpose  of  clearness,  and  in  order  to  avoid  nomenclature 
which  implies  an  origin  of  the  growths  in  one  or  other  of  the 
embryonic  layers,  the  term  hypernephroma  will  be  used  for  those 
growths  which  resemble  the  suprarenal  gland  in  structure,  and 
terms  such  as  adenoma,  carcinoma,  sarcoma,  will  be  eschewed. 
Isolated  examples  of  the  following  tumours  have  been  described, 
viz.  glioma,  neuroma,  glio-fibro-myoma,  angioma,  lymphangioma, 
lipoma,  and  cysts. 

The  most  common  form  of  new  growth  in  the  suprarenal  gland 
has  the  histological  characters  of  the  gland.  (Plate  12.)  Both 
benign  and  malignant  hypernephroma  are  described,  the  latter 
showing  a  great  preponderance. 

These  hypernephromas  have  the  histological  character  of  the 
cortex  of  the  gland.  There  is  a  framework  of  capillary  blood- 
vessels upon  which  polygonal  cells  are  directly  set.  The  cells  ad- 
jacent to  the  capillary  wall  are  regularly  arranged,  those  more 
distant  are  irregularly  packed  together.  In  the  meshes  of  the 
vascular  network  the  cells  become  arranged  in  alveolar  form  or 
in  long  columns.  The  cells  are  large  and  polygonal  in  shape,  and 
have  a  large  nucleus,  and  the  protoplasm  is  frequently  vacuo- 
lated, the  vacuoles  having  originally  contained  fat.  Rarely, 
melanotic  granules  are  found  in  the  protoplasm.  The  tumours 
are  single  or  multiple.  They  are  rounded,  and  possess  a  fibrous 
capsule  which  sends  supporting  septa  into  the  interior  of  the 
growth.  They  have  the  characteristic  yellow  colour  of  supra- 
renal tissue,  and  frequently  show  haemorrhages  in  the  tumour 
substance. 

The  benign  tumours  are  small  in  size,  and  may  be  single  or 
multiple.  The  cells  are  smaller,  more  uniform  in  size,  and  more 
regularly  arranged  in  long,  narrow  columns. 

The  cells  of  the  malignant  hypernephioma  are  less  uniform  and 
may  show  great  irregularity  in  size,  shape,  and  arrangement. 
They  may  attain  the  size  of  a  small  melon.  Metastases  take 
place  by  the  blood  stream,  and  deposits  are  found  in  the  lungs, 
bones,  and  liver. 

In  the  malignant  growths  portions  may  be  observed  which 
have  the  appearance  described  as  characteristic  of  the  benign 
growths,  and  transition  forms  are  found. 

Etiology. — New  growths  of  the  adrenals  are  found   both  in 


224  THE   KIDNEY  [chap. 

adults  and  in  children.  About  one-third  occur  in  infancy  and 
childhood.  G-arceau  gives  a  list  of  25  cases  in  children,  19  of 
which  occurred  in  infants  and  children  of  4  years  and  under. 
Females  are  more  frequently  affected  at  this  age,  and  the  left 
side  more  often  than  the  right. 

Symptoms. — The  symptomatology  consists  in  certain  general 
symptoms  and  the  appearance  of  an  abdominal  tumour.  Hsema- 
turia  is  very  rare  (2*9  per  cent.- — Ramsay),  and  when  it  occurs  is 
due  to  passive  congestion  of  the  kidney  from  involvement  of  the 
renal  vein. 

Progressive  emaciation  is  the  most  characteristic  feature  of 
the  disease.  There  are  loss  of  strength  and  weight,  and  profound 
anaemia.  Anorexia,  vomiting,  constipation,  and  sometimes  oedema 
are  observed. 

The  pigmentary  changes  characteristic  of  complete  destruc- 
tion of  the  adrenal  tissue  as  seen  in  tuberculous  disease  are  very 
rarely  observed.  Ramsay  found  bronzing  of  the  skin  in  3  out  of 
37  cases,  but  in  9  others  there  was  brownish  discoloration  of 
the  skin. 

In  children  there  is  the  same  emaciation,  and  there  may  also  be 
an  arrest  of  mental  development,  the  child  being  dull  and  stupid. 

Certain  changes  in  regard  to  growth  and  development  are 
of  extreme  interest.  There  may  be  unilateral  hypertrophy. 
Hutchinson  has  recorded  the  case  of  a  male  child  of  4  years  in 
which  there  was  hypertrophy  of  the  left  thigh,  leg,  and  arm,  and 
of  the  paired  organs  on  the  same  side.  Precocious  puberty  is  a 
frequent  characteristic  of  hypernephroma  in  children.  In  Gar- 
ceau's  list  it  occurred  in  10  out  of  25  cases.  There  is  excessive 
growth  of  hair  on  the  face,  pubes,  and  elsewhere.  Early  and 
excessive  development  of  the  genital  organs  occurs  in  either  sex, 
and  abnormal  development  of  the  clitoris  may  lead  to  an  erroneous 
diagnosis  of  hermaphroditism. 

In  the  earlier  stages  a  tumour  is  not  detected,  as  it  lies  high 
up  under  the  ribs.  Later  a  tumour  can  be  detected  in  the  hypo- 
chondriac region.  The  bowel  lies  in  front  of  it,  and  gives  a  tym- 
panitic note.  The  kidney  may  sometimes  be  recognized  pushed 
down  by  the  growth,  and  occasionally  a  distinct  groove  between 
the  kidney  and  growth  may  be  detected.  The  tumour  appears 
at  the  level  of  the  8th  and  sometimes  the  7th  costal  cartilage,  and 
extends  towards  the  middle  line. 

Extreme  mobility  of  the  tumour  is,  according  to  Morris,  a 
diagnostic  point  of  some  importance. 

Pain  is  usually  present,  and  is  referred  along  nerves,  and 
sometimes  to  distant  parts  of  the  body. 


XV]  ADRENAL  TUMOURS  225 

In  a  considerable  proportion  of  cases  there  are  no  symptoms 
directly  pointing  to  the  seat  of  growth,  which  may  remain  un- 
suspected, and  only  be  revealed  by  post-mortem  examination. 

In  children  the  first  sign  may  be  a  secondary  gro\vth  in  the 
bones,  the  orbit  being  frequently  aflected. 

Diagnosis. — The  majority  of  cases,  when  a  tumour  appears, 
have  been  diagnosed  as  renal  growths. 

The  most  characteristic  features  of  suprarenal  growths  are 
the  absence  of  changes  in  the  urine,  the  early  and  extreme  emacia- 
tion, pigmentary  and  developmental  changes,  and  the  appearance 
of  the  tumour  at  the  level  of  the  7th  or  8th  costal  cartilage  and 
its  growth  towards  the  middle  line,  whereas  growths  of  the  kidney 
appear  at  the  costal  margin  between  the  9th  and  11th  costal  car- 
tilages. The  lower  border  of  the  suprarenal  growth,  fused  with 
the  kidney,  is  broad  and  almost  horizontal ;  suprarenal  tumours 
are  very  mobile.  The  injection  of  collargol  into  the  renal  pelvis 
and  subsequent  radiographic  examination  (pyelography)  is  a  very 
important  means  of  distinguishing  between  suprarenal  and  renal 
growths.  Rarely  suprarenal  growths  have  been  mistaken  for 
tumours  of  the  liver  or  gall-bladder. 

Prognosis. — The  growth  of  hypernephroma  is  rapid,  and 
metastases  take  place  early.  The  average  duration  of  life  after 
the  first  onset  of  symptoms  is  from  six  to  ten  months  (Ramsay). 

Treatment. — Early  removal  of  the  tumour,  together  \\ath 
the  kidney,  is  the  only  radical  method  of  treatment.  There  is 
danger  of  severe  haemorrhage  and  of  opening  the  pleural  cavity 
during  the  separation  of  adhesions. 

Morris  collected  11  cases  of  removal  of  suprarenal  tumours 
with  5  deaths  and  6  recoveries.  Of  the  latter  only  one  patient 
was  known  to  be  alive  eighteen  months  after  the  operation,  and 
most  of  them  died  in  a  few  months  from  recurrence.  In  children 
the  operation  is  peculiarly  fatal. 

LITERATURE 

Bulloch  and  Sequeira,   Trans.   Path.  Soc.   Lond.,  1905,  Ivi.   157. 

Ferrier  et  Leceae,  Bev.  de  Ghir.,  1906,  xxvi.  325. 

Garceau,   Tumours  of  the  Kidney.     1909. 

Hutchinson,  Quart.  Journ.  of  Med.,  1907,  i.  33. 

Israel,  Deuts.  med.   Woch.,  1905,  xxxi.  746. 

Linser,  Beitr.  z.  klin.  Chir.,  1903,  xxxvii.  296. 

Morris,  Surgical  Diseases  of  the  Kidney  and  Ureter,  ii.  14.     1901. 

Ramsay,  Johns  Hopkins  Hosp.  Bull.,  1899,  p.  25. 


CHAPTER  XVI 
INFECTIVE  DISEASES 

TUBERCULOSIS  OF   THE  KIDNEY  AND  URETER 

Tuberculosis  of  the  urinary  organs  may  occur  without  other 
active  foci  of  tubercle  being  present  in  the  body,  or  it  may  be 
secondary  to  active  tuberculosis  of  the  genital  system,  or  to  tuber- 
culosis of  some  other  organ  such  as  the  lung. 

The  combination  of  genital  and  urinary  tuberculosis  is  very 
frequently  met  with  in  the  male,  rarely  in  the  female. 

Tuberculosis  of  the  kidney  is  said  to  be  primary  or  secondary. 
In  the  strict  sense  primary  tuberculosis  of  the  kidney  does  not 
occur  as  it  does  in  the  lung.  There  is  always  a  focus  in  some  other 
part  of  the  body.  The  term  is  used  in  the  narrower  sense  that 
the  kidney  is  the  primary  focus  in  the  urinary  system. 

Renal  tuberculosis  occurs  (1)  as  a  part  of  an  acute  miliary 
tuberculosis,  both  kidneys  being  strewn  with  mihary  tubercles; 
(2)  as  a  tuberculous  infiltration  of  the  kidney 

Miliary  tuberculosis  occurs  in  early  childhood  and  as  an  in- 
significant part  of  a  general  tuberculous  infection.  It  has  no 
surgical  interest. 

Tuberculous  infiltration  of  the  kidney  forms  about  10  per 
cent,  of  tuberculous  infections. 

Method  of  infection. — The  tubercle  bacilli  reach  the  kidney 
by  one  of  three  paths  : 

1.  Ascending. 

2.  Haematogenous. 

3.  Lymphatic. 

L  Ascending  infection  {secondary  renal  tuberculosis).  — 
Ascending  infection  was  long  regarded  as  the  usual  method  of 
infection  of  the  kidney.  This  view  was  based  upon  the  occur- 
rence of  early  symptoms  of  cystitis  and  supported  by  some  post- 
mortem examinations  and  the  results  of  experiments. 

Albarran  produced  tuberculosis  of  the  kidney  by  injecting 
tubercle  bacilli  into  the  ureter  after  ligature  of  the  duct,  and  Wild- 
bolz  more  recently  obtained  similar  results  without  ligature.     On 

226 


CHAP.  XVI]  RENAL  TUBERCULOSIS  227 

the  other  hand,  Giani  could  not  produce  ascending  tuberculosis 
by  introducing  tubercle  bacilli  into  the  bladder,  and  Brongersma 
has  shown  clinically  that  vesical  tuberculosis  may  remain  limited 
to  the  bladder,  without  ascending  to  the  kidney,  during  a  period 
of  twelve  years.  Halle  and  Motz  have  been  unable  to  find  a  single 
clinical  or  pathological  example  which  proved  that  ascending 
infection  had  taken  place.  It  is,  therefore,  doubtful  if  ascending 
infection  takes  place  at  all.  Within  the  kidney  itself,  according 
to  Ekehorn,  ascending  may  be  found  along  with  descending  lesions. 
From  a  single  focus  of  hsematogenous  origin  in  the  renal  tissue 
the  bacteria  enter  the  canaliculi,  cause  ulceration  of  the  papillae, 
and  spread  upwards  towards  the  base  of  the  pyramid  along  the 
lymphatics. 

2.  Haematogenous  infection  {descending  infection,  primary 
injection). — Experiments  by  Albarran  show  that  if  tubercle  bacilli 
are  injected  hypodermically  and  the  ureter  of  one  kidney  is 
ligatured,  tuberculosis  develops  in  this  kidney ;  and  this  has  been 
confirmed  by  other  observers. 

Clinically,  tuberculosis  of  the  kidney  is  very  frequently  found 
without  vesical  tuberculosis,  and  the  after-history  of  cases  of 
nephrectomy  shows  that  the  original  focus  was  in  the  kidney. 
Pathological  specimens  also  show  primary  tuberculosis  of  the 
kidney  without  any  other  lesion  of  the  urinary  organs. 

3.  Lymphatic  infection. — Brongersma  holds  that  lymphatic 
is  more  probable  than  haematogenous  or  ascending  infection.  He 
believes  that  the  primary  tuberculous  focus  is  situated  in  the 
thorax.  In  62  out  of  71  cases  of  renal  tuberculosis  there  were 
symptoms  of  tuberculosis  of  the  lung  or  pleura  on  the  same  side 
as  the  affected  kidney.  Infection  of  the  kidney  takes  place 
through  the  mediastinal  lymphatic  glands,  and  by  a  retrograde 
lymph  current  produced  by  pleural  adhesions  the  bacilli  pass  to 
the  renal  lymphatics.  This,  he  believes,  explains  the  unilateral 
distribution  of  renal  tuberculosis. 

The  more  frequent  occurrence  of  bilateral  caseous  tubercu- 
losis in  children  is  explained  by  the  occurrence  of  bilateral  tuber- 
culous thoracic  glands  in  children  and  the  comparatively  large 
size  of  the  lymphatic  vessels. 

A  history  of  bygone  pleurisy  is  certainly  frequently  obtained  in 
cases  of  renal  tuberculosis,  but  I  have  not  seldom  found  that  the 
pleurisy  was  on  the  side  opposite  to  the  renal  tuberculosis. 

Of  the  three  paths  of  infection  there  is  more  evidence  in  favour 
of  the  haematogenous  than  of  the  others.  The  ascending  form, 
although  it  has  been  proved  experimentally  to  be  possible,  is 
very  rare  clinically,  if  indeed  it  occurs  at  all. 


228  THE  KIDNEY  [chap. 

Etiology. — Eenal  tuberculosis  is  most  frequent  between  the 
ages  of  20  and  40.  It  is  uncommon  in  cbildhood  and  rare  in 
old  age.  "Women  are  more  frequently  affected  than  men  in  the 
proportion  of  33  to  15  (Kiimmel). 

Renal  tuberculosis  is  unilateral  in  the  earUer  and  very  fre- 
quently bilateral  in  the  late  stages.  This  accounts  for  some  dis- 
crepancy between  the  statistics  of  different  observers.  Kronlein 
states  that  92  per  cent,  and  Legueu  85  per  cent,  of  cases  are  uni- 
lateral, and  chnical  e"vddence  obtained  by  catheterization  of  the 
ureters  and  the  results  of  nephrectomy  certainly  supports  this 
view.  Such  statements  must  always  be  subject  to  the  qualifica- 
tion that  they  apply  to  the  early  stage  of  the  disease.  In  the  late 
stage  the  disease  in  a  large  proportion  of  the  cases  is  bilateral, 
although  Halle  and  Motz  found  89  unilateral  out  of  131  post- 
mortem examinations,  which  may  be  taken  to  represent  the  late 
stage  of  the  disease. 

Experimental  evidence  goes  to  show  that  injury  to  a  kidney 
will  determine  the  development  of  tuberculosis  in  that  organ. 
This  is  not  borne  out  by  clinical  experience.  Although  a  few 
patients  may  give  a  history  of  a  blow  on  the  loin,  it  is  not  cer- 
tain that  the  disease  was  not  already  present ;  and,  further,  the 
development  of  tuberculosis  in  a  kidney  which  is  known  to  have 
been  ruptured  is  very  rare,  nor  do  I  know  of  any  instance  in 
which  a  kidney  that  has  been  explored  by  nephrotomy  and  found 
healthy  has  afterwards  developed  tuberculosis. 

The  right  kidney  is  rather  more  often  affected  than  the  left, 
and  this,  together  with  the  fact  that  women  are  more  hable  to  the 
disease,  and  that  the  right  kidney  in  the  female  is  more  frequently 
movable,  has  led  to  the  supposition  that  undue  mobihty  may 
have  damaged  the  kidney  and  led  to  the  deposit  of  tubercle.  The 
proportion  of  movable  tuberculous  kidneys  is,  hawever,  very 
small  (5  per  cent. — Kiister). 

The  tubercle  bacillus  is  present  alone  in  the  majority  of  cases, 
but  there  may  be  secondary  infections  with  the  bacillus  coh,  the 
streptococcus,  or  the  staphylococcus  albus. 

Pathological  anatomy. — A  large  number  of  types  of  tuber- 
culous kidney  have  been  described,  most  of  which  are  merely 
stages  of  development  of  the  same  process  without  any  funda- 
mental difference.  The  following  have  outstanding  features  which 
permit  of  their  being  described  as  varieties  of  tuberculous  kidney : 

1.  Miliary  tuberculosis. — Apart  from  the  acute  bilateral 
miliary  tuberculosis  which  is  of  no  surgical  interest,  some  authors 
have  described  a  chronic  unilateral  mihary  tuberculosis  in  which 
the  kidney  is  strewn  with   small  greyish-yeUow  tubercles.     In  a 


tK  r/iHRKTCri  SHIELLS.. 


Tuberculosis  of  kidney,  ulcero-cavernous  type  ;  operation  specimen. 
Disease  confined  to  upper  branch  of  pelvis  ;  ulceration  of 
apices  of  pyramids,  with  secondary  miliary  tubercles  in  cortex. 
Note  great  fibrous  thickening  and  contraction  at  neck  of 
branch  of  pelvis,  an  attempt  to  shut  ofi'  this  segment.      (P.  229.) 


Plate  13. 


Acute  tuberculosis  of  kidney  with  mixed  infection ;  operation 
specimen.  Ulcero-cavernous  form  affecting  whole  of  pyramids, 
also  pelvis  and  ureter ;  extensive  secondary  miliary  tuberculosis. 
(P.  229.) 


Plate  14. 


XVI]  RENAL   TUBERCULOSIS  229 

large  proportion  of  the  iilcero-cavernous  form  there  are  miliary 
tubercles  in  varying  numbers  in  the  cortex  or  the  medulla,  and 
this  is  the  only  form  of  miliary  tuberculosis  of  the  kidney  which 
is  seen  surgically. 

2.  Ulcero-cavernous  form. — This  is  the  most  common  form 
of  surgical  tuberculosis  .of  the  kidney.  It  consists  essentially  in 
progressive  destruction  by  ulceration  from  the  pelvis  outwards 
towards  the  surface  of  the  kidney  substance,  and  the  organ  is  not 
enlarged. 

In  the  earliest  form  there  is  intense  congestion  and  commencing 
ulceration  at  the  apex  of  a  pyramid  (Plate  13)  at  the  upper  or  lower 
pole.  The  ulceration  progresses  from  apex  to  base  of  p}'Tamid 
until  the  pp-amid  is  entirely  scooped  out.  Several  pyramids  may 
be  attacked,  and  the  tissues  between  either  become  thickened  so 
as  to  produce  separate  pockets,  or  are  broken  down  to  form  a  larger 
cavity.  (Plate  14.)  The  cavity  is  lined  with  an  irregular  caseous 
layer,  outside  of  which  is  a  narrow  greyish  layer,  and  beyond  this  a 
zone  of  intense  congestion.  In  the  cortex  corresponding  to  these 
pyramids,  and  sometimes  also  in  the  columns  of  Bertini  between 
them,  solitary  grey  tubercles  or  groups  of  tubercles  are  dotted. 
There  may  be  a  single  group,  or  the  whole  cortex  may  be  strewn 
with  them.  The  area  of  ulceration  usually  corresponds  to  the  area 
over  which  the  tubercles  are  distributed.  In  some  examples  of  this 
form  of  kidney  these  tubercles  are  absent. 

In  almost  all  kidneys  thus  attacked  examination  will  show 
an  attempt  to  shut  off  the  tuberculous  area  from  the  rest  of  the 
pelvis  by  fibrous  thickening  and  contraction  of  the  mouth  of  a 
calyx  or  of  a  large  branch  of  the  pelvis  into  which  several 
ulcerated  calyces  open  (Plate  13),  or  of  the  pelvo-ureteral  jmiction. 
The  commmiication  between  the  diseased  part  of  the  pelvis  and 
the  remaining  part  may  be  very  narrow.  It  may  be  completely 
obliterated,  and  a  partial  or  total  hydronephrosis  results. 

Commencing  ulceration  may  be  found  at  the  apex  of  a  pyra- 
mid at  the  lower  pole,  with  advanced  ulceration  at  the  upper 
pole.  Microscopically  the  wall  of  the  cavity  shows  an  inner  layer 
of  caseous  material,  a  middle  layer  of  tubercles  with  giant  cells, 
and  an  outer  layer  of  renal  tissue  infiltrated  with  round  cells. 
The  whole  kidney,  or  one  pole  only,  may  be  much  enlarged.  On 
the  surface  the  diseased  part  is  seen  as  rounded  bosses,  which  are 
soft  to  the  touch.  In  the  early  stage  the  kidney  may  appear 
normal  on  the  surface,  or  there  may  be  a  group  of  small  yellow 
tubercles  immediately  under  the  fibrous  capsule. 

3.  Caseous  or  massive  tuberculosis  of  the  kidney. — This 
is  a  much  less  common  form.     The  kidney  substance  is  replaced 


230  THE   KIDNEY  [chap. 

by  large  irregular  or  rounded  masses  of  yellowish-white  caseous 
material  of  putty-like  consistence.  The  tissue  separating  these 
is  fibrous,  and  bacilli  are  rarely  found.  This  is  an  obsolete,  very 
advanced  form  of  the  ulcero-cavernous  type,  and  is  a  variety  of 
tuberculous  hydronephrosis.     (Plate  17.) 

4.  Tuberculous  hydronephrosis. — Where  the  thickening  and 
contraction  of  the  wall  of  one  segment  of  the  pelvis  or  of  a  single 
calyx  continues  to  the  point  of  obliteration,  or  where  the  same 
process  develops  at  the  outlet  of  the  ureter,  a  partial  or  total  tuber- 
culous hydronephrosis  results.  (Plate  15.)  The  fluid  contained 
in  the  pockets  is  pale,  and  turbid  with  flakes  of  tuberculous 
debris.  The  lining  of  the  cavities  is  irregular  and  of  greyish-white 
colour,  and  beyond  this,  separating  the  pockets  and  enclosing 
the  whole,  is  a  dull  greyish-brown  fibrous  wall.  (Plate  15.) 
When  a  partial  hydronephrosis  develops,  the  rest  of  the  kidney 
may  be  the  seat  of  the  ulcero-cavernous  type  of  disease. 

Both  this  and  the  preceding  form  (3)  are  "  closed,"  i.e.  shut 
off  from  the  rest  of  the  urinary  tract,  so  that  there  may  be  no 
clinical  evidence  of  renal  tuberculosis. 

Infection  of  the  tuberculous  hydronephrosis  will  produce  a 
pyonephrosis. 

A  polycystic  renal  tuberculosis  in  which  the  renal  substance 
is  transformed  into  very  numerous  small  cysts  separated  by 
sclerosed  renal  tissue  has  been  described,  but  is  very  rare. 

5.  Toxic  lesions  of  the  kidney. — Acute  nephritis,  parenchy- 
matous nephritis,  interstitial  nephritis,  and  waxy  disease  of  the 
kidney  are  observed  in  the  kidneys  of  tuberculous  patients.  These 
lesions  are  due  to  the  action  of  the  toxin  of  the  tubercle  bacillus 
on  the  kidney.  They  may  be  found  in  the  kidneys  when  the 
tuberculous  focus  is  elsewhere  in  the  body,  or  may  be  present 
in  the  non-ulcerated  and  non-caseous  part  of  the  tuberculous 
kidney,   or  in  the  second  kidney. 

It  has  recently  been  shown  by  Lecene  that  a  fibrous  form  of 
nephritis  may  be  directly  caused  by  the  tubercle  bacillus,  with 
the  production  of  giant  cells,  but  without  any  trace  of  caseation. 

6.  Lesions  of  the  renal  pelvis  and  ureter. — The  pelvis 
of  the  kidney  becomes  involved  in  all  cases.  Inflammation  of 
varying  severity,  with  ulceration,  extends  from  the  part  of  the 
pelvis  draining  the  diseased  segment  of  the  kidney  to  the  general 
cavity.  One  or  more  calyces  of  the  pelvis  may  be  affected  and 
the  rest  be  apparently  normal,  the  disease  reappearing  at  the 
upper  end  of  the  ureter  and  extending  down  that  duct.  Again, 
there  may  be  a  small  portion  of  the  upper  part  of  the  pelvis  affected 
and  the  rest  healthy,  except  a  single  calyx  at  the  lower  pole. 


Tuberculosis  of  kidney,  final  stage  :  tuberculous  hydronephrosis. 
(P.  230.) 


Plate  15. 


XVI]  RENAL   TUBERCULOSIS  231 

The  whole  pelvis  may  be  ulcerated  and  inflamed. 

When  one  branch  of  the  pelvis  is  affected,  the  wall  may  become 
greatly  thickened  and  cartilaginous  at  the  outlet  of  the  diseased 
into  the  healthy  portion,  and  the  communication  between  these 
may  be  very  narrow.  Further  narrowing  will  cause  a  partial 
hydronephrosis.  Stenosis  of  the  upper  end  of  the  ureter  causes 
distension  of  the  pelvis  and  kidney,  and  complete  tuberculous 
hydronephrosis,  which  is  completely  shut  off  from  the  bladder. 
The  fatty  tissue  around  the  pelvis  becomes  greatly  increased, 
sclerosed,  and  adherent. 

7.  Lesions  of  the  ureter. — The  ureter  is  infected  with 
tubercle  bacilli  conveyed  by  the  urine.  Superficial  ulcers  of  the 
mucous  membrane  may  be  found  scattered  along  the  lumen  of 
the  tube.  More  frequently,  however,  there  are  extensive  changes 
in  the  wall  of  the  duct.  It  is  thickened  to  the  size  of  the  little 
finger,  hard  and  rigid.  On  section  there  is  a  thick,  hard,  fibrous 
ring,  and  inside  this  the  diseased  mucous  membrane,  which  shows 
extensive  ulceration.  The  lumen  is  small  and  filled  with  tuber- 
culous debris.  Sometimes  the  lumen  is  completely  blocked  with 
masses  of  caseous  material.  The  ureter  is  adherent  to  the  peri- 
toneum. There  may  be  one  or  more  patches  of  tuberculous 
ulceration  in  the  course  of  the  ureter,  and  the  rest  of  the  tube 
normal. 

8.  Lesions  of  the  perirenal  tissues.— The  fatty  capsule  is 
greatly  thickened,  coarse,  fibrous,  and  densely  adherent  to  the 
surrounding  structures.  The  fat  at  the  hilum  and  along  the  renal 
vessels,  and  along  the  aorta  and  inferior  vena  cava,  is  also  fibrous 
and  adherent,  and  occasionally  enlarged  glands,  discrete  or  in 
masses,  are  found  adherent  to.  these  vessels. 

On  microscopical  section  giant-cell  systems  are  found  in  the 
perirenal  fat  (Legueu). 

9.  Condition  of  the  second  kidney. — Bilateral  tuberculosis 
is  found  in  a  certain  proportion  of  cases  {see  p.  228).  The  infection 
may  very  rarely  reach  the  second  kidney  by  ascending  from  the 
bladder  which  has  become  tuberculous.  The  usual  method  is 
by  the  blood  stream. 

Where  the  second  kidney  has  not  become  infected  by  the 
tubercle  bacillus,  toxic  lesions  may  be  present  {see  p.  230). 

Symptoms.  1.  Vesical  symptoms.  —  The  symptoms  of 
tuberculosis  of  the  kidney,  through  nearly  the  whole  course  of 
the  disease,  may  be  entirely  confined  to  the  bladder. 

It  is  a  frequent  experience,  when  examining  patients  whose 
only  trouble  has  been  cystitis  of  a  mild  grade,  to  find  one  kidney, 
and  occasionally  both,  the  seat  of  advanced  tuberculosis. 


232  THE   KIDNEY  [chap. 

The  symptoms  of  cystitis  commence  insidiously  with  gradu- 
ally increasing  frequency  of  micturition.  At  first  there  is  in- 
creased frequency  and  urgency  of  micturition  during  the  day  only, 
but  later  there  is  nocturnal  frequency,  and  this  increases  until 
the  patient  passes  water  during  the  night  as  often  as,  or  more  fre- 
quently than,  during  the  day.  Finally,  there  may  be  nocturnal 
incontinence.  Bazy  regards  this  nocturnal  frequency  as  a  very 
important  sign  of  inflammation  of  the  kidney.  There  is  some 
scalding  on  micturition,  and  often  pain  towards  the  end  of  the 
act.     Occasionally  there  is  a  slight  terminal  hsematuria. 

2.  Changes  in  the  urine. — Polyuria  is  an  early  symptom  of 
tuberculosis,  and  it  may  be  proved,  by  ureteral  catheterization,  to 
exist  only  on  the  diseased  side.  It  is  said,  to  be  more  marked  at 
night.  The  urine  is  very  pale  and  opalescent,  faintly  acid  or 
neutral,  and  hazy  with  a  small  amount  of  well-mixed  pus.  It 
is  lacking  in  pigment  to  a  greater  degree  than  one  would  expect 
from  the  amount  of  the  polyuria,  Hcematuria  is  a  variable  symp- 
tom. It  may  be  entirely  absent  or  only  present  in  microscopic 
quantities.  There  may  be  slight  persistent  terminal  hsematuria 
with  vesical  symptoms,  and  here  the  blood  emanates  from  the 
bladder.  In  some  cases  there  is  an  outburst  of  haemorrhage  at 
the  beginning  of  the  illness,  occasionally  before  other  symptoms 
have  appeared.  I  have  observed  an  attack  of  hsematuria  as  long 
as  two  years  before  the  onset  of  other  symptoms.  This  initial 
hsematuria  was  probably  due  to  congestion  of  the  organ;  occa- 
sionally it  is  due  to  a  focus  of  tubercle  which  becomes  temporarily 
shut  off  from  the  pelvis.  Severe  hsematuria  may  also  occur  during 
the  course  of  the  disease,  and  usually  follows  some  strain  or  injury. 
It  may  be  the  dominant  symptom  and  necessitate  operation.  Albu- 
minuria may  be  present  before  the  appearance  of  pyuria,  when 
the  urine  is  still  clear  (Bazy).  This  premonitory  albuminuria  may 
come  from  the  sound  kidney  as  well  as  from  the  diseased  organ 
(Legueu).  The  urine  contains  pus  and  sometimes  blood  corpuscles, 
and  tube  casts  may  also  be  present.  The  percentage  of  urea  and 
chlorides  is  reduced, 

3.  Pain. — There  may  be  no  history  of  pain  in  a  kidney  which 
is  completely  destroved  by  tuberculosis.  Aching  pain  is  some- 
times complained  of,  and  the  patient  may  not  be  able  to  lie  on 
the  affected  side. 

Reno-ureteral  colic  is  sometimes  present  from  the  passage  of 
clots  or  debris,  or  from  the  blockage  of  a  ureter  by  further  sweUing 
of  a  thick  mucous  membrane.  Pain  at  the  neck  of  the  bladder 
and  at  the  tip  of  the  penis  at  the  end  of  micturition,  and  scalding 
along  the  urethra,  are  due  to  cystitis. 


XVI]  RENAL  TUBERCULOSIS  233 

Examination  of  kidney  and  ureter. — On  examination  of 
the  abdomen  the  kidney  is  not  usually  enlarged.  If  it  can  be  felt 
it  is  sometimes  hard  and  somewhat  irregular.  The  kidney  is  fre- 
quently tender.  In  the  late  stages  the  kidney  may  be  small  and 
shrunken  so  that  it  cannot  be  detected.  The  organ  is  occasionally 
felt  to  be  enlarged.  In  this  case  there  is  usually  hypertrophy 
from  destruction  of  the  second  kidney,  or  partial  or  complete 
hydronephrosis. 

There  is  frequently  tenderness  along  the  line  of  the  ureter,  and 
the  duct  can  be  felt  as  a  thick  cord  on  deep  palpation  of  the 
abdomen.  Per  rectum  in  the  male  a  thick  tender  cord  can  be 
felt  above  the  prostate,  and  passing  outwards  and  upwards  to 
the  side  of  the  pelvis.  In  the  vagina  the  thick  tuberculous 
ureter  can  readily  be  detected  passing  outwards  from  near  the 
middle  of  the  anterior  vaginal  wall,  and  it  can  be  rolled  be- 
neath the  finger  on  the  lateral  wall  of  the  vagina. 

The  second  kidney  in  unilateral  tuberculosis  may  be  enlarged, 
painful  and  tender  from  hypertrophy,  with  or  without  commencing 
tuberculosis. 

There  is  usually  progressive  loss  of  weight  and  lassitude,  which 
are  partly  explained  by  the  disturbed  sleep  consequent  upon  the 
frequent  micturition. 

Course  and  prognosis. — The  onset  of  symptoms  of  uncom- 
plicated tuberculosis  of  the  kidney  is  insidious  and  the  course  slow. 
When  the  symptoms  have  become  fully  established,  fluctuations 
are  frequently  observed.  For  months  the  symptoms  abate,  and 
the  patient  may  apparently  improve,  only  to  relapse  later.  These 
fluctuations  are  due  to  external  influences  such  as  climate, 
surroundings,  and  diet,  and  in  a  measure  also  to  the  tendency 
to  which  I  have  pointed  for  the  disease  to  become  partly  shut  ofi 
by  fibrous  contraction  from  the  rest  of  the  renal  pelvis.  In  some 
cases  the  symptoms  cease  and  the  pus  and  tubercle  bacilli 
disappear  from  the  urine.  Recurrence  of  symptoms  takes  place 
after  some  months  or  even  several  years  (in  one  case  after 
eleven  years),  and  may  follow  a  blow  or  some  exciting  cause. 
On  the  whole,  however,  there  is  gradual  advance  of  the  disease 
until  death  takes  place  several  years  (four  to  seven  or  even  ten) 
after  the  first  symptoms.  It  is  generally  accepted  that  spontaneous 
cure  of  tuberculosis  of  the  kidney  can  only  occur  in  the  most  ex- 
ceptional cases,  and  that  the  disease  progresses  until  the  organ  is 
completely  destroyed. 

Where  septic  infection  is  superadded  the  progress  is  much  more 
rapid.  Infection  may  be  heematogenous,  but  most  frequently 
follows  infection   of   the   bladder,  the   result   of   sounding   or    of 


234  THE  KIDNEY  [chap. 

irrigation.  Fever  appears,  and  the  ureter  may  become  blocked 
and  pyonephrosis  develop. 

The  dangers  of  renal  tuberculosis  are  that  it  may  spread  to 
the  bladder,  that  the  second  kidney  may  become  affected  with 
tuberculosis  or  nephritis,  that  the  tuberculous  infection  may  involve 
other  organs,  or  that  septic  infection  may  follow. 

Death  takes  place  from  anuria  when  both  kidneys  are  invaded, 
or  from  exhaustion  when  septic  infection  is  superadded. 

Diagfnosis. — It  is  necessary  first  to  make  a  diagnosis  of  tuber- 
culosis of  the  kidney  and  then  to  examine  the  extent  of  the  disease. 

Type  I  :  symptoms  of  cystitis  with  pyuria  and  de- 
tection of  the  tubercle  bacillus  in  the  urine. — This  is 
the  most  frequent  clinical  type.  The  symptoms  of  cystitis  appear 
insidiously  in  a  young  patient,  are  persistent  and  increasing.  A 
bacteriologist  accustomed  to  the  examination  of  urine  for  the 
tubercle  bacillus  seldom  fails  to  discover  the  bacillus,  which  may 
be  present  in  very  small  numbers  or  may  be  abundant  and  some- 
times in  chain-like  form. 

The  bacillus  may  be  found  in  the  urine  of  tuberculous  patients 
without  urinary  tuberculosis  being  present.  The  existence  of 
pyuria  and  hsematuria  and  of  other  signs  is  sufficient  to  differentiate 
these  cases  from  those  of  tuberculous  bacilluria.  The  tuberculin 
reaction  obtained  by  subcutaneous  injection  or  by  rubbing  tuber- 
culin into  an  excoriation,  or  the  ophthalmic  reaction  of  Calmette, 
may  be  useful,  but  I  have  seldom  obtained  any  help  from  these 
methods  where  any  real  doubt  existed. 

One  kidney  may  be  enlarged  or  tender,  and  the  ureter  is  thick 
and  tender. 

Cystoscopy  may  show  that  the  bladder  is  healthy  and  that  the 
vesical  symptoms  are  reflex.  On  the  other  hand,  there  may  be 
cystitis,  and  the  examination  is  then  more  difficult.  A  general 
cystitis  may  be  found  without  typical  appearances  of  tuberculosis, 
or  there  may  be  tubercles  or  tuberculous  ulceration.  The  changes 
at  the  ureteric  orifice  are  important.  There  may  be  cystitis  and 
thickening  of  the  lips  of  the  ureter  with  inflammation  around  it, 
and  sometimes  greyish  tubercles  on  the  lips  or  in  the  immediate 
neighbourhood,  or  tuberculous  ulceration  (Plate  16,  Fig.  2).  The 
lips  of  the  ureter  may  be  ulcerated  and  eaten  away,  and  surrounded 
by  grey  tubercles.  There  may  be  one  or  two  or  a  collection  of 
tiny  cysts  around  the  orifice.  In  an  advanced  stage  the  ureter 
is  open  and  trumpet-shaped,  with  extensive  ulceration  around. 
In  old-standing  tuberculosis  of  the  kidney  with  thickening  and 
shrinkage  of  the  ureter  the  ureteric  orifice  is  dragged  upwards  and 
outwards  (Plate  16,  Fig.  3)  and  appears  like  a  tunnel  (Fen wick). 


?3 


O     c 


S      o 


^    :i 


V    c 

u     o 


XVI]        RENAL   TUBERCULOSIS :  DIAGNOSIS       235 

The  urine  of  each  kidney  should  be  obtained  and  examined 
separately.  Separators  are  difficult  to  use,  and  give  fallacious 
results  when  the  bladder  is  affected.  Catheterization  of  the  ureters 
is  the  only  reliable  method.  When  cystitis  is  present  in  a  mode- 
rate degree  no  great  difficulty  is  experienced,  but  when  there  is 
extreme  sensitiveness  of  the  bladder  the  operation  may  be  diffi- 
cult. It  may  be  necessary  to  make  more  than  one  attempt,  and 
sometimes  to  wait  for  some  weeks  until  an  acute  cystitis  has  sub- 
sided under  treatment  before  the  catheterization  can  be  done 
successfully.  Where  catheterization  of  the  ureter  has  failed  it 
has  been  suggested  that  the  ureter  be  catheterized  after  opening 
the  bladder  suprapubically,  or  even  that  a  temporary  ligature 
be  placed  upon  the  ureter  in  order  to  obtain  the  urine  from  the 
other.  It  is  better  to  wait  until  the  acute  symptoms  have  sub- 
sided, and  to  give  a  course  of  tubercuhn  (T.R.)  before  again 
attempting  the  catheterization ;  and  these  measures  failing,  the 
supposed  healthy  kidney  should  be  explored  by  lumbar  nephro- 
tomy and  carefully  examined. 

Where  one  ureter  is  obviously  diseased,  only  that  of  the  sup- 
posed healthy  kidney  need  be  catheterized,  since  that  is  the  organ 
concerning  which  information  is  desired.  If  both  ureters  appear 
healthy,  catheterization  of  both  is  necessary.  The  following  is 
the  report  of  the  urines  drawn  by  catheter  from  both  kidneys  in 
a  case  of  tuberculosis  of  one  organ  : 

Right  Kidney  {Tuberculous)  Left  Kidney  (Healthy) 

95  c.c.  180  c.c. 

Neutral.  Sharply  acid. 

Sp.  gr.  1007.  Sp.  gr.  1024. 

Albumin — moderate  amount.  Albumin  absent. 

Blood  present.  Blood  absent. 

Sugar  absent.  Sugar,   0-729  gnn.   (phloridzin 

glycosuria). 

Urea,  0"55  per  cent.  Urea,  2-4  per  cent. 

A  fair  amount  of  pus.  No  pus. 

Tubercle  bacilli  fairly  numerous.  No  tubercle  bacilli. 

Without  examination  of  the  unblended  urines  of  the  two 
kidneys  it  is  impossible  to  form  a  reliable  judgment  as  to  the 
state  and  fmictional  power  of  the  second  kidney. 

Type  2  :  enlargement  of  the  kidney. — Enlargement  of  the 
kidney  usually  occurs  in  the  late  stage  when  other  signs  of  tuber- 
culosis are  present. 

Rarely  a  tuberculous  hydronephrosis  may  be  completely  shut 
off  from  the  bladder.  I  have  observed  such  a  case  when  a  hydro- 
nephrotic  movable  tuberculous  kidney  was  present.     There  was  no 


236  THE   KIDNEY  [chap. 

change  in  the  urine,  but  the  ureter  on  the  diseased  side  was  dragged 
out  of  place  and  very  thick.  In  other  cases  there  is  no  change  at 
the  ureteric  orifice. 

There  is  a  danger  of  mistaking  a  large  hypertrophied  and 
recently  infected  kidney  for  the  only  diseased  kidney  when  the 
other  kidney  has  been  quietly  destroyed.  Only  catheterization  of 
the  ureters  and  examination  of  the  separated  urines  will  demon- 
strate the  true  state  of  the  kidneys. 

The  X-rays  usually  show  enlargement  of  the  renal  shadow  and 
an  increase  in  the  opacity  of  the  organ.  Occasionally  caseous 
masses  throw  a  dense  defined  shadow  (Plate  17),  and  this  may 
be  so  sharp  in  outline  as  to  resemble  a  calculus  or  a  collection  of 
calcuh. 

Type  3  :  haetnaturia. — This  may  occur  in  the  form  of  initial 
haematuria  above  described.  Where  the  tuberculous  foci  are  buried, 
in  the  substance  of  the  kidney  it  may  be  impossible  to  obtain 
the  bacillus  in  the  urine  or  to  find  any  change  apart  from  the 
haematuria. 

In  such  a  case  there  is  nothing  to  distinguish  the  condition 
from  a  small  new  growth  or  from  hsemorrhagic  nephritis,  before 
exploration  of  the  kidney  which  is  bleeding. 

Treatment 

The  treatment  of  renal  tuberculosis  is  dependent  upon  the 
exact  diagnosis  of  the  extent  of  the  disease.  Before  considering 
the  question  of  operation  it  is  necessary  to  have  information  on 
the  following  points  : — 

Is  there  tuberculous  cystitis  ? 

Is    there   a   second    Iddney,    and,    if    so,   is    it    healthy  or 
diseased  ? 

Are  there  tuberculous  foci  elsewhere  in  the  body  ? 
This  is  obtained  by  the  methods  already  described. 

The  following  methods  of  treatment  will  be  discussed : — 

Tuberculin  treatment. 

Medicinal  and  climatic  treatment. 

Operative  treatment. 
Tuberculin  treatment.  1.  Tuberculosis  of  one  kidney 
alone. — It  is  impossible  to  speak  with  certainty  in  regard  to  the 
effect  of  tuberculin  upon  the  early  stage  of  renal  tuberculosis, 
when  one  organ  only  is  affected,  for  extensive  observations  on 
the  subject  are  wanting.  I  have  used  it  in  a  number  of  cases. 
where  operation  has  for  some  reason  been  impracticable.  In  some 
of  these  cases,  after  treatment  for  one  or  two  years,  tubercle  bacilli 
and  all  signs  of  inflammation  have  disappeared   from   the  urine 


Shadow  thrown  by  caseous  tubercle  of  left  kidney. 
Each  segment  represents  a  calyx  filled  with  putty- 
like material.  The  upper  arrow  points  to  a  fibrous 
septum,  the  lower  to  a  caseous  mass.  (Pp.  230, 
236.) 


Pi  ATE    17. 


XVI]      RENAL  TUBERCULOSIS :  TREATMENT       237 

and  there  have  been  no  further  symptoms.  The  tuberculous  focus 
in  these  cases  has  been  shut  ofE  and  is  apparently  quiescent.  It  is 
not  certain,  however,  that  this  is  permanent,  as  sufficient  time 
has  not  yet  elapsed  since  the  symptoms  disappeared.  In  other 
cases  the  symptoms  continued  and  the  tuberculosis  progressed. 
The  results  of  early  nephrectomy  in  unilateral  renal  tuberculosis 
are  so  good  that,  in  order  to  justify  the  adoption  of  tuberculin 
as  a  routine  treatment,  a  series  of  cases  known  to  be  cured  by 
tuberculin  must  be  shown.  This  has  not  up  to  the  present  time 
been  done. 

The  cases  of  unilateral  renal  tuberculosis  that  may  be  selected 
for  tuberculin  are  those  where  operation  has  been  refused.  An 
•exception  may  perhaps  be  made  in  renal  tuberculosis  in  children. 
The  frequency  with  which  the  disease  is  bilateral  in  the  early 
stage  in  young  children  is  much  greater,  and  the  difficulties  in 
accurate  diagnosis  by  modern  methods  are  more  formidable.  In 
such  cases  tuberculin  may  be  used  in  place  of  operation. 

2.  Tuberculosis  of  both  kidneys. — In  such  cases  operative 
interference  is  contra-indicated,  and  tuberculin  should  be  tried. 

I  have  not  met  with  a  cure,  or  any  case  approaching  a  cure, 
in  cases  of  this  class.  There  has,  however,  been  undoubted  im- 
provement after  the  institution  of  the  tuberculin  treatment. 
When  the  disease  is  so  extensive  a  considerable  period  of  time 
might  be  expected  to  elapse  before  the  full  effect  of  the  tuberculin 
is  obtained.  Such  a  period,  unfortunately,  is  seldom  afforded  in 
these  cases  before  death  takes  place  from  intercurrent  infection 
or  renal  failure. 

The  treatment  should  be  commenced  with  very  small  doses 
-and  carried  on  with  great  caution,  for  there  is  some  danger  of 
blocking  of  the  already  obstructed  ureters  if  a  reaction  and 
swelling  of  the  mucous  membrane  take  place. 

If  the  injections  are  followed  by  renal  pain  or  by  a  rise  of 
temperature,  or  an  increase  of  fever  already  present,  they  should 
be  stopped,  or  the  dose  much  reduced. 

3.  Tuberculosis  of  one  kidney  with  tuberculous  foci  in 
other  parts. — ^A  frequent  combination  is  renal  and  genital 
tuberculosis.  Tuberculin  treatment  is  often  of  service  in  these 
cases,  either  in  combination  with  nephrectomy  or  apart  from 
operation. 

After  nephrectomy  tuberculin  treatment  of  the  genital  tuber- 
culosis is  likely  to  be  successful.  Tuberculosis  of  the  kidney  may 
occur  with  active  tuberculosis  of  the  lungs,  bones,  or  joints.  My 
experience  of  tuberculin  in  these  cases  has  not  been  encouraging. 
There  was  improvement  in  the  renal  disease  in  some  of  the  cases, 


238  THE   KIDNEY  [chap. 

but  the  extrarenal  foci  were  unaffected  or  even  appeared  to 
increase  under  the  treatment.  When  the  extrarenal  disease  was 
quiescent  it  could  be  ignored  in  the  treatment  of  the  renal 
tuberculosis. 

Tuberculin  treatment  should  be  commenced  with  a  dose  of 
Totoo  2ig.  to  yoVo  £ELg.  (T.R.),  and  the  injection  given  once  a  week 
or  once  a  fortnight,  and  cautiously  increased.  If  a  reaction  occurs 
a  longer  interval  and  a  smaller  dose  should  be  used.  The  treat- 
ment extends  over  one  or  several  years,  and  the  tuberculin  may 
be  given  continuously,  or  in  courses  of  two  or  three  months  with 
an  interval  of  one  or  two  months. 

Progress  is  measured  by  the  increase  or  decrease  of  body  weight, 
the  general  feeling  of  vigour,  the  effect  on  pain,  frequency  of  mic- 
turition, tenderness,  enlargement  of  the  kidney,  and  hsematuria. 
Where  vesical  symptoms  are  present  the  amelioration  of  these 
frequently  provides  a  most  striking  demonstration  of  improvement. 
The  specific  gravity  and  pigmentation  of  the  urine  increase  as  the 
renal  condition  improves.  The  quantity  of  pus  and  the  presence 
and  numbers  of  tubercle  bacilh  are  critical  tests  of  progress. 

Climatic  and  medicinal  treatment. — A  warm  climate 
without  great  variations  in  temperature  is  most  suitable  (Egypt, 
Morocco,  South  Africa).  Nourishing  diet  with  plenty  of  milk  and 
fats  should  be  recommended.  Urotropine  is  unnecessary  imless 
septic  infection  is  present,  and  it  may  irritate  the  hypersensitive 
bladder.     Sandal-wood  oil  soothes  the  vesical  irritation. 

Washing  the  bladder  should  be  interdicted.  It  is  useless 
therapeutically,  and  there  is  very  great  danger  of  introducing  sepsis. 

Operative  treatment. — The  operations  which  may  be  per- 
formed for  tuberculosis  of  the  kidney  are  partial  nephrectomy, 
total  nephrectomy,  and  nephrotomy. 

Partial  nephrectomy. — This  operation  consists  in  removal  of 
the  diseased  part  of  the  kidney.  It  has  been  practised  in  isolated 
cases  by  Israel,  Watson,  Morris,  Godlee,  and  others,  and  has  been 
recommended  in  the  early  stage  of  renal  tuberculosis.  In  prac- 
tice, however,  it  is  found  that  at  this  early  stage  it  is  impossible 
to  make  certain  how  much  of  the  kidney  is  affected.  On  sur- 
face inspection  the  organ  may  appear  normal,  or  one  pole  may 
appear  tuberculous  and  the  rest  of  the  kidney  healthy  when  the 
disease  has  already  affected  both  poles.  For  this  reason  partial 
nephrectomy  has  not  been  widely  adopted,  and  the  opinion  is 
practically  universal  at  the  present  time  that  total  nephrec- 
tomy is  the  only  radical  operation  that  should  be  practised  for 
tuberculosis  of  the  kidney. 

Nephrectomy. — Nephrectomy  in  the  early  stage  of  renal  tuber- 


XVI]      RENAL  TUBERCULOSIS:  TREATMENT      239 

culosis  is  the  only  method  by  which  a  cure  can  be  assured,  and 
the  operation  is  indicated  whenever  the  diagnosis  of  unilateral 
renal  tuberculosis  is  made. 

Nephrotomy  is  reserved  for  certain  cases  that  are  unsuitable 
for  nephrectomy,  and  is  a  purely  palliative  operation. 

The  indications  for  and  against  nephrectomy  are  as  follows  : — 

1.  Bilateral  tuberculosis. — When  both  kidneys  are  proved  to  be 
tuberculous  nephrectomy  cannot  be  recommended. 

The  disease  is  always  more  advanced  in  one  kidney  than  in 
the  other,  and  it  may  he,  open  to  discussion  whether  the  removal 
of  the  organ  in  which  the  disease  is  more  advanced  will  not 
prolong  life.  If  we  set  aside  general  tuberculosis,  which  is  a 
rare  accident  in  tuberculous  disease  of  the  kidney,  and  is  not 
likely  to  be  affected  by  the  removal  of  one  of  two  tuberculous 
organs,  the  dangers  to  which  a  patient  with  bilateral  renal  tuber- 
culosis is  exposed  are  two  :  (i)  toxaemia  due  to  absorption  from  the 
tuberculous  foci ;    (ii)  anuria  from  destruction  of  the  renal  tissue. 

In  so  far  as  the  general  health  is  suffering  from  the  absorp- 
tion of  toxins  from  the  diseased  area,  considerable  benefit  will 
accrue  from  removal  of  one  focus  of  disease,  and  it  is  also  certain 
that  the  second  and  fimctionally  the  more  active  kidney  will  be 
reheved  of  the  irritation  caused  by  the  excretion  of  toxins  from 
the  blood.  But,  on  the  other  hand,  the  period  of  life  remaining 
to  the  patient  is  also  measured  by  the  quantity  of  active  renal 
tissue  which  he  possesses.  By  nephrectomy  of  the  more  diseased 
organ  some  functional  renal  tissue  is  removed,  even  when  the 
tuberculous  inflammation  is  far  advanced.  The  whole  work  of 
secretion  is  thus  thrown  upon  the  remaining  kidney.  In  some 
cases  the  removal  of  even  this  small  amount  of  renal  tissue  leaves 
the  patient  with  too  little  active  secreting  tissue,  and  anuria 
follows  the  operation.  In  other  cases  the  patient  survives  the 
operation,  but  after  a  short  period  death  from  anuria  takes  place. 

Unless  it  is  proved  by  the  examination  of  the  urine  obtained 
by  the  ureteric  catheter  and  by  the  various  tests  of  the  renal 
function  that  the  disease  of  the  second  kidney  is  in  a  very  early 
stage,  and  unless  it  is  ob\dous  that  the  health  of  the  patient 
is  suffering  to  a  marked  degree  from  the  absorption  of  toxins 
from  the  first  kidney,  nephrectomy  of  the  more  diseased  kidney 
in  bilateral  tuberculosis  is  contra-indicated. 

2.  Non-tuberculous  nephritis  of  the  second  kidney. — A  slight 
degree  of  chronic  nephritis  is  very  frequently  present  in  the  second 
kidney.  This  is  shown  by  the  presence  of  albumin  and  granular 
and  hyaline  tube  casts  in  the  urine,  and  is  due  to  the  excretion 
of  toxins.     It  does  not,  however,  contra-indicate  nephrectomy  of 


240  THE   KIDNEY  [chap. 

the  tuberculous  kidney  unless  the  nephritis  is  advanced.  The 
urine  from  this  kidney  must  be  examined,  and  the  tests  for  the 
renal  function  carried  out,  in  order  to  ascertain  the  extent  of 
the  renal  disease.  Should  these  prove  satisfactory,  nephrectomy 
should  be  performed. 

3.  Tuberculous  lesions  of  the  hladder. — Tuberculous  cystitis 
does  not  contra-indicate  nephrectomy  if  it  is  proved  that  the 
second  kidney  is  healthy.  The  removal  of  the  tuberculous  kidney 
has  usually  a  most  beneficial  effect  upon  the  disease  of  the  bladder. 
The  cystitis  may  subside  without  further  local  treatment. 

The  use  of  tuberculin  after  nephrectomy  in  these  cases  has 
given  most  satisfactory  results  in  my  hands.  Where  the  tuber- 
culous infection  has  become  mixed  with  colon-bacillus  or  other 
infections  the  prognosis  is  not,  however,  so  good. 

4.  Tuberculous  lesions  of  other  organs. — Obsolete  tuberculous 
foci,  such  as  spinal  curvature,  ankylosed  joints,  healed  tuberculous 
disease  of  bones  or  glands,  do  not  contra-indicate  nephrectomy, 
although  for  anatomical  reasons  the  operation  may  be  rendered 
more  difficult. 

In  active  tuberculous  disease  of  the  genital  system  nephrectomy 
may  be  performed  if  the  genital  disease  is  not  widespread.  In  a 
case  where  both  epididymes,  both  seminal  vesicles,  and  the  pros- 
tate are  ajEEected,  nephrectomy  would  be  contra-indicated,  but  in 
less  extensive  lesions,  such  as  unilateral  tuberculous  epididymitis, 
nephrectomy  and  epididymectomy  may  be  performed.  When 
renal  tuberculosis  is  complicated  by  active  spinal  caries,  psoas 
abscess,  tuberculous  arthritis,  pulmonary  phthisis,  and  other  such 
serious  lesions,  nephrectomy  is  contra-indicated. 

5.  The  general  state  of  the  'patient. — It  is  occasionally  necessary 
to  refuse  primary  nephrectomy  on  account  of  an  enfeebled  general 
state,  apart  from  any  of  the  complications  above  described.  Second- 
ary nephrectomy  may  sometimes  be  possible  in  these  cases  after 
nephrotomy. 

Technique. — The  retroperitoneal  route  is  invariably  chosen  for 
the  removal  of  a  tuberculous  kidney.  An  oblique  lumbar  incision 
gives  the  most  satisfactory  access. 

The  operation  is  simple  or  complicated,  according  to  the  absence 
or  presence  of  perinephritic  inflammation. 

Nephrectomy  in  an  early  stage  of  renal  tuberculosis,  before 
the  perinephritic  fat  has  become  dense  and  sclerosed,  presents 
no  difficulties  or  unusual  features.  On  exposing  the  organ  the 
outward  appearance  may  not  suggest  that  it  contains  any  disease, 
and  palpation  does  not  detect  any  change  in  consistence.  In 
such  a  case  the  value  of  the  previous  examination  of  the  urine 


XVI]     RENAL  TUBERCULOSIS:    TREATMENT     241 

from  each  kidney  becomes  evident.  The  kidney  is  removed  with- 
out being  incised,  and  the  danger  of  infecting  the  wound  with 
tubercle  is  avoided.  The  ureter  is  first  isolated  and  carefully 
examined.  Whether  thickened  or  not,  it  should  be  cut  across 
between  two  ligatures,  and  each  end  seared  with  the  cautery  or 
touched  with  pure  carbolic  acid.  The  pedicle  is  ligatured,  and  the 
kidney  removed.  Legueu  recommends  that  the  perirenal  fat  be 
dissected  away,  as  there  are  frequently  tuberculous  deposits  in  it. 

When  there  has  been  perinephritis  the  fatty  capsule  is  trans- 
formed into  a  thick,  firm,  adherent  fibro-fatty  mass,  and  a  sub- 
capsular nephrectomy  becomes  necessary.  The  kidney  is  exposed 
and  stripped  from  its  capsule  with  the  forefinger,  great  care  being 
taken  not  to  rupture  the  tuberculous  cysts,  the  walls  of  which 
are  thin  and  easily  torn.  If  the  kidney  is  converted  into  a  large 
pyonephrosis  it  may  be  advisable  to  tap  it,  and  so  reduce  the  size 
and  diminish  the  possibility  of  rupturing  the  wall  of  the  sac  during 
the  enucleation.  This  is  seldom  necessary,  however,  and  if  it  is 
done  the  most  stringent  precautions  must  be  observed  to  prevent 
soiHng  of  the  wound  with  the  escaping  tuberculous  material.  The 
puncture  is  made  with  a  trocar  and  cannula  after  protecting  the 
wound  with  large  gauze  swabs,  and  the  puncture  wound  is  closed 
by  pressure  forceps  over  gauze  during  the  remaining  stages  of  the 
operation.    After  removal  of  the  kidney  the  cavity  must  be  drained. 

Treatment  of  the  ureter. — When  the  ureter  is  normal  in  appear- 
ance it  is  ligatured  and  dropped  into  the  wound.  When  it  is 
thickened  and  tuberculous,  one  of  three  courses  may  be  pursued : 

1.  The  upper  end  may  be  fixed  in  the  lumbar  wound. 

2.  The  upper  end  may  be  ligatured,  cauterized,  and  dropped 

into  the  retroperitoneal  space  after  removing  the  kidney. 

3.  The  ureter  may  be  excised. 

L  The  fixation  of  the  upper  end  of  the  tuberculous  ureter  in 
the  lumbar  wound  has  been  done  with  a  view  to  ureterectomy 
at  a  later  date.  A  tuberculous  sinus  results ;  and  in  one  case  in 
which  I  did  this  the  lumbar  wound  became  extensively  infected 
with  tubercle  and  only  healed  after  some  months. 

2.  When  the  upper  end  is  dropped  into  the  retroperitoneal 
space  after  being  ligatured  and  cauterized,  the  tuberculous  pro- 
cess in  the  majority  of  cases  becomes  quiescent  and  the  tube  is 
gradually  transformed  into  a  fibrous  cord. 

Zuckerkandl  found  that  a  sinus  followed  nephrectomy  more 
frequently  where  the  ureter  had  been  left  intact. 

Occasionally  tuberculous  cystitis  appears  to  be  kept  up  by 
the  persistence  of  tuberculosis  in  such  a  ureter. 

3.  In  order  to  excise  the  ureter  the  oblique  lumbar  incision  is 
Q 


242 


THE  KIDNEY 


[chap. 


prolonged  forwards  beyond  the  anterior  superior  iliac  spine  and 
runs  parallel  to  Poupart's  ligament  and  about  IJ  in.  above  it  to 
about  the  naiddle  of  its  extent.  The  patient  should  be  placed  in 
the  Trendelenburg  position  in  order  to  reach  the  pelvic  portion 
of  the  ureter.  The  thick  rigid  tube  is  easily  traced  down  into 
the  pelvis.  The  adhesions  may  give  rise  to  some  difficulty  in 
isolating  it.  In  the  male  subject  the  ureter  can  be  traced  to  the 
bladder  and  there  ligatured  and  cut  across.  In  the  female,  the 
pelvic  portion  of  the  ureter  is  concealed  in  the  broad  ligament 
and  the  tube  must  be  cut  across  behind  this.  Kelly  has  removed 
the  lower  portion  of  the  tuberculous  ureter  and  a  portion  of  the 
bladder  wall  through  the  vagina. 

The  advisabihty  of  performing  an  extensive  operation  for  the 
removal  of  the  ureter  at  the  end  of  nephrectomy  will  depend 
upon  the  state  of  the  patient  and  the  duration  of  the  nephrectomy. 
The  ureterectomy  should  only  be  performed  if  the  nephrectomy 
has  passed  off  smoothly  and  the  patient's  strength  is  well 
maintained.  Most  authorities  are  content  to  remove  "  as  much 
as  possible  "  of  the  ureter,  which  means  that  the  ureter  is  traced 
over  the  brim  of  the  pelvis  and  cut  across  in  the  descending 
part  of  its  pelvic  course,  leaving  the  remaining  portion  of  the 
pelvic  ureter.  This  operation  occupies  less  time  and  necessitates 
less  extensive  dissection  than  the  more  complete  removal  of  the 
ureter ;  it  protects  the  lumbar  wound  against  the  possibility  of 
infection  from  the  ureter,  and  the  small  stump  does  not  give  rise 
to  any  further  trouble.    On  these  grounds  it  is  to  be  recommended. 

Instead  of  carrying  the  lumbar  incision  forwards,  a  second 
small  vertical  or  transverse  incision  may  be  made  above  Poupart's 
ligament,  the  peritoneum  pushed  aside,  and  the  thickened  ureter 
seized,  drawn  out,  and  ligatured  as  low  as  possible. 

Immediate  mortality  of  nephrectomy  for  primary  tuberculosis. — 
The  following  figures  are  given  by  Brongersma  : — 


Surgeon 

NefTirectomies 

Deaths  from 
operation 

Per  cer 

Albarran 

..108 

3 

2-77 

Brongersma    . 

58 

3 

517 

Casper 

19 

2 

10-52 

Israel   . . 

97 

\             11 

11-34 

Kronlein 

34 

2 

5-88 

Kiimmel 

.69 

3 

4-35 

Pousson 

.20 

2 

10-00 

Rafin    . . 

40 

5 

12-50 

Rovsing 

47 

3 

6-38 

Zuckerkandl   . 

23 

3 

1304 

515 


37 


XVI]    RENAL  TUBERCULOSIS:  TREATMENT      24' 


This  gives  an  operative  mortality  of  7'18  per  cent,  in  515  cases. 
There  has  been  a  steady  and  rapid  decrease  in  the  mortality  of 
nephrectomy  for  tuberculous  disease  of  the  kidney,  as  the  follow- 
ing figures  show : — 


1885  (Gross)      .  . 

. .      90-00  per  cent 

1893  (Vigneron) 

. .      38-40 

1896  (Israel)       .  . 

. .      18-00 

1908  (Brongersma) 

7-18 

The  improvement  in  the  statistics  was  due  in  the  earlier  years 
to  more  complete  asepsis  and  to  improved  methods  of  treating 
surgical  shock  and  more  perfect  technique,  as  well  as  to  experience 
in  the  selection  of  cases  suitable  for  operation.  Recently  the 
great  advance  in  the  methods  of  early  diagnosis  and  examination 
of  the  renal  function  afforded  by  catheterization  of  the  ureters 
and  the  use  of  the  phloridzin  and  other  tests  has  led  to  further 
reduction  of  the  mortality. 

As  Brongersma  points  out,  when  from  the  list  of  operations 
only  the  statistics  of  surgeons  who  use  modern  methods  of  diagnosis 
as  a  routine  measure  are  taken  (the  operations  performed  previous 
to  the  introduction  of  these  methods  being  excluded),  the  mortality 
falls  to  2-85  per  cent. 

A  more  recent  series  of  statistics  was  published  in  1911,i  from 
which  the  following  are  selected  : — 


Surgeon 

Cases 

Immediate  mortality 

Remote  mortality 

Israel 
Wildbolz     .  . 

(1,023    collected) 

<_    170  personal   j 

139 

Within  six  months : 
12-9  per  cent. 
2-8 

Up  to  two  years : 
10-15-0  per  cent. 
15-0  per  cent. 

Asakura 

70 

5-7 

Up  to  four  years : 
7-1  per  cent. 

Andre 

57 

3-5 

15-0 

von  Frisch .  . 

100 

10-0 

9-0 

After-results. — The  after-history  of  369  patients  on  whom 
nephrectomy  was  performed  for  primary  tuberculosis  shows  that 
death  occurred  after  a  considerable  interval  in  56  cases  (15-2  per 
cent.).  In  these  cases  the  interval  varied  from  one  or  two  to 
fourteen  or  sixteen  years.  In  the  great  majority  of  the  fatal 
cases  the  patients  died  within  the  first  two  years.  Thus,  in  329 
cases   of   nephrectomy,   35    (10-6  per  cent.)  of  the  patients  died 

III.  Kongress  der  deutschen  Gesellschaft  fiir  Urologie,  Sept.,   1911. 


244  THE   KIDNEY  [chap. 

during  the  first  two  years.  In  these  cases  the  fatal  result  would 
be  due  to  a  spread  of  the  tuberculous  process. 

Of  184  patients  surviving  two  years  after  nephrectomy  for 
tuberculosis,  only  6  (3-2  per  cent.)  died  of  tuberculosis  later. 

It  may  be  stated,  therefore,  that  there  is  a  risk  amounting 
to  10-6  per  cent,  of  the  patient  dying  of  tuberculosis  during  the 
first  two  years,  and  a  risk  of  3-2  per  cent,  of  a  fatal  result  from 
tuberculosis  after  this. 

Nephrotomy. — Nephrotomy  is  a  preUminary  or  a  palhative 
operation  in  tuberculosis  of  the  kidney,  and  is  indicated  under 
the  following  conditions  : — 

1.  Where  it  is  impossible,  from  the  state  of  the  bladder,  to 
catheterize  the  ureter  and  obtain  information  in  regard  to  the 
state  of  the  second  kidney,  the  obviously  tuberculous  organ  is 
drained.  After  an  interval  the  cystitis  subsides  and  the  examina- 
tion can  be  carried  out. 

Casper  has  recommended  that  in  these  very  rare  circumstances 
the  diseased  kidney  should  be  exposed,  its  ureter  compressed, 
an  injection  of  indigo  carmine  given,  and  the  urine  collected  from 
the  bladder  by  a  catheter.  By  this  method  the  functional  power 
of  the  second  kidney  is  tested. 

2.  Nephrotomy  of  the  supposed  healthy  kidney  is  performed 
when  other  methods  of  examination  have  failed  to  give  satis- 
factory evidence  of  the  presence  or  absence  of  disease. 

3.  As  a  preliminary  operation  to  nephrectomy  where  the 
general  condition  of  the  patient  is  much  enfeebled.  Secondary 
nephrectomy  is  performed  some  weeks  later  when  the  patient 
has  regained  strength. 

In  late  stages,  when  the  frequent  and  painful  micturition  are 
very  distressing,  it  has  been  suggested  that  one  kidney  should  be 
removed  and  the  ureter  of  the  other  brought  to  the  surface  of 
the  loin. 

4.  Where  both  kidneys  are  tuberculous,  to  relieve  {a)  a  col- 
lection of  tuberculous  material,  (b)  excessive  haemorrhage  or  severe 
pain,  (c)  profound  toxaemia. 

The  mortahty  of  nephrotomy  is  high.  Pousson,  in  his  per- 
sonal statistics,  found  an  operative  mortahty  of  27 "5  per  cent, 
for  nephrotomy  and  6'54  per  cent,  for  primary  nephrectomy.  A 
fistula  persists  during  the  lifetime  of  the  patient.  In  a  few  cases 
the  fistula  has  closed  after  the  kidney  has  been  entirely  destroyed. 

LITERATURE 

Albarran,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1908,  p.  81. 
Brongersma,  I*^"'  Congres  de  I'Assoc.  Internat.  d'Urol.,  Paris,  1908,  p.  533. 
Casper,  Deuts.  med.  Woch.,  1905,  p.  98;   Semaine  Med.,  1908,  p.  288. 


XVI]  RENAL  ACTINOMYCOSIS  245 

LITERATURE— contrnwerf 

Garceau,  Boston  Med.  and  Surg.  Journ.,  1902,  ii.  13. 

Hall^  Ob  Motz,  Ann.  d.  Mai.  d.  Org.  Gen.-  JJrin.,  1906,  i.  162. 

Krdnlein,  Folia  Urol,  1908,  p.  245. 

Kiimmel,  Arch.  f.  klin.Chir.,  1906,  p.  270. 

Legueu,  Rev.  de  Chir.,  1909,  p.  86. 

Lichtenstein,  ZeUs.  f.  Urol.,  1908,  p.  219. 

Pousson,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1905,  i.  801. 

Rochet,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1909,  p.   1226. 

Tendeloo,  Milnch.  ined.  Woch.,  1905. 

Walker,  Thomson,  Pract.,  May,  1908. 

Zuckerkandl,  Zeits.  f.  Urol.,  1908,  p.  97. 

ACTINOMYCOSIS   OF   THE   KIDNEY 

Actinomycosis  affects  the  kidney  either  as  a  metastatic  deposit 
or  by  direct  continuity.  The  number  of  cases  on  record  is  com- 
paratively small.  In  an  excellent  chapter  Garceau  collects  the 
known  facts  regarding  the  disease  in  the  kidney. 

In  the  early  condition  there  are  miliary  pale-yellow  tubercles  in 
the  cortex  of  the  kidney.  These  have  a  radiating  structure  at  the 
edge,  due  to  the  characteristic  clubbed  bodies  closely  set  together. 
Around  these  bodies  there  is  inflammation  and  softening,  and 
small  abscesses  form  containing  the  actinomycotic  masses  as 
yellow  granules.  The  abscesses  are  numerous,  and  the  inter- 
vening kidney  tissue  shows  chronic  interstitial  inflammation. 
The  abscesses  may  discharge  into  the  pelvis,  and  the  urine  con- 
tains pus  and  yellow  granules. 

The  metastatic  form  is  derived  from  a  focus  in  some  internal 
organ  such  as  the  intestine  or  appendix. 

A  perinephritic  abscess  may  form,  and  there  may  be  rupture 
on  the  surface  of  the  body.  Amyloid  degeneration  is  frequently 
present  in  the  kidneys  when  actinomycosis  affects  some  other 
organ,  and  it  may  also  be  observed  when  the  kidney  itself  is  the 
seat  of  actinomycosis. 

Where  the  disease  is  confined  to  the  kidney  the  symptoms  are 
those  of  suppurative  pyelonephritis  of  a  mild  type. 

In  a  young  man  of  35  operated  upon  by  Israel  an  explora- 
tory nephrotomy  had  previously  been  performed  for  hsematuria. 
A  year  later  there  was  pyuria  with  pain,  and  the  heematuria 
reappeared.  High  fever  and  rigors  followed.  Improvement  took 
place,  but  three  years  later  the  scar  broke  down  and  pus  with 
yellow  granules  was  discharged.  Israel  removed  the  kidney,  the 
upper  two-thirds  of  which  was  the  seat  of  actinomycosis,  while 
the  pelvis  contained  a  stone. 

When  other  organs  are  seriously  involved  the  metastatic  deposit 
in  the  kidney  forms  an  insignificant  part  of  the  disease.    Nephrec- 


246  THE   KIDNEY  [chap. 

tomy  is  justifiable  only  when  the  disease  of  the  kidney  is  the  sole 
or  the  most  important  focus  of  disease.  Iodide  of  potassium 
should  be  given  in  as  large  doses  as  the  patient  will  tolerate,  and 
arsenic  may  also  be  administered.  Iodides  have  not  been  so  suc- 
cessful in  the  treatment  of  actinomycosis  as  was  at  one  time 
anticipated. 

LITERATURE 

Ammentorp,  Centralbl.  f.  Chir.,  1894,  xxi.  1074. 

Garceau,   Tumours  of  the  Kidney.     1909. 

Israel,  Bed.  klin.  Woch.,  1889,  Nos.  7,  8  ;  Munch,  med.  Woch.,  1899,  xlvi.  49. 

Ruhrah,  Ann.  Surg.,  1899,  p.  417. 

BILHAEZIOSIS   OF   THE   KIDNEY  AND   URETER 

Bilharzial  lesions  of  the  kidney  are  very  rare.  In  a  few  cases 
the  ova  have  been  found  in  the  renal  pelvis  and  in  the  substance 
of  the  organ.  Grebel  found  them  in  the  kidneys  in  advanced 
pyelonephritis,  and  other  lesions  such  as  interstitial  nephritis, 
subcapsular  cysts,  etc.,  have  been  observed.  Rufier  discovered 
calcified  ova  of  bilharzia  in  the  straight  tubules  of  the  kid- 
neys in  two  Egyptian  mummies  of  the  Twentieth  Dynasty 
{1250-1000  B.C.). 

In  the  pelvis  there  are  haemorrhages  and  ulcerations ;  a  cal- 
culus may  form  with  the  bilharzial  ova  as  a  nucleus.  The  mucous 
membrane  may  be  covered  with  grey-yellow  plaques  formed  by 
blood  pigment,  uric-acid  crystals,  and  ova. 

The  bilharzial  lesions  most  frequently  afiect  the  lower  part  of 

the  ureter,  but  the  whole  length  of  the  duct  may  be  involved. 

Lesions    similar   to   those    observed   in   the   bladder    are    found. 

According    to     Kartuhs,     annular     striae    of     the     mucosa     are 

characteristic    of    bilharzia  of    the  ureter.     The    lumen   may  be 

contracted    and   obliterated,    and    dilatation    of    the   ureter   and 

hydronephrosis  result. 

LITERATURE 

Debove,  Achard,  et  Castaigne,  Maladies  des  Eeins.     1906. 

Madden,  Bilharziosis.     1907. 

Rufier,  Brit.  Med.   Journ.,  Jan.  1,  1910. 

SYPHILIS   OF   THE   KIDNEY 

1.  Nephritis  due  to  secondary  syphilis  is  very  rare.  The  lesions 
are  bilateral,  and  take  the  form  of  the  large  white  kidney.  The 
microscopical  lesions  are  principally  epithelial.  In  old-standing 
lesions  interstitial  nephritis  with  changes  in  the  glomeruli  and 
blood-vessels  are  found. 

In  slight  cases  there  is  a  trace  of  albumin  in  the  urine  and 


x\nl  RENAL  SYPHILIS  247 

slightly  marked  cedema.  In  severe  cases  there  are  oUguria,  pro- 
nounced albuminuria,  with  red  cells,  epithelial  casts,  and  a  few 
leucocytes  in  the  urine  ;  nausea,  vomiting,  anasarca  are  observed ; 
urgemia  may  supervene,  and  the  patient  dies  in  spite  of  treatment. 
In  those  who  recover,  chronic  nephritis  frequently  persists. 

2.  Tertiary  svphilis  may  affect  the  kidney  in  the  form  of  nephritis 
or  gummata. 

S^'philitic  nephritis  in  the  tertiary  stage  takes  the  form  of 
subacute  or  chronic  interstitial  nephritis,  or,  less  frequently,  of 
parenchvmatous  nephritis.  The  disease  is  frequently  unilateral, 
and  may  affect  one  part  of  the  kidney.  Scarring  of  the  kidney 
is  sometimes  found.  In  a  man  aged  50,  who  had  contracted 
svphilis  fifteen  years  pre\aously,  and  had  suffered  from  severe 
hsematuria  with  ureteral  clots  for  ten  months,  the  left  kidney  was 
non-adherent,  and  on  the  convex  border  near  the  lower  pole  there 
was  a  depressed  scar  with  a  thickened  adherent  fibrous  capsule 
over  it.  On  microscopical  section  of  a  wedge  of  kidney  tissue  at 
this  part  there  was  fi^brosis  of  the  capsule,  and  areas  of  fibrosis 
were  scattered  through  the  cortex.  The  hsematuria  ceased  after 
the  operation. 

Gummata  are  single  or  multiple,  and  may  be  associated  with 
tertiary  lesions  of  other  organs.  There  may  be  as  many  as  twenty 
or  more  small  pea-sized  gummata,  or  a  single  large  mass.  The 
gummata  commence  in  the  interstitial  tissue,  and  have  a  yellowish 
colour.  Their  characters  are  those  of  gummata  found  elsewhere. 
The  rest  of  the  kidney  substance  may  be  the  seat  of  nephritis. 
A  large  gumma  replaces  the  renal  tissue,  so  that  the  kidney  is 
enlarged,  hard,  and  irregular.  Such  kidneys  have  been  mistaken 
for  malignant  growth  or  tuberculous  disease  and  operated  upon. 
Bowlby  and  Israel  have  performed  nephrectomy  under  these 
conditions. 

Amyloid  degeneration  occurs  in  tertiary  syphilis,  and  may 
coexist  with  gummata  of  the  kidneys  or  other  organs. 

3.  Congenital  syphiHs  may  affect  the  kidney  during  foetal  life 
and,  as  Stoerk  has  shown,  cause  arrest  or  delay  of  development, 
so  that  at  birth  the  outer  layer  of  the  cortex  contains  imperfectly 
formed  tubules  and  glomeruli. 

During  infancy  and  childhood  acute  or  chronic  interstitial 
nephritis  is  the  usual  form  of  the  disease.  The  condition  is  most 
frequently  bilateral,  but  one  kidney  or  a  part  of  one  kidney  may 
be  affected. 

Treatment. — The  diet  and  general  management  of  these  cases 
differ  in  no  way  from  those  of  other  forms  of  nephritis.  Salvarsan 
should  be  avoided ;  merciury  should  be  given  in  small  doses  and 


248  THE   KIDNEY  [chap,  xvi 

with  caution.     Some  authorities  beheve  that  mercury  is  harmful. 
In  tertiary  lesions  it  should  be  combined  with  iodides. 

Nephrectomy  has  been  performed  under  a  mistaken  diagnosis, 
but  has  proved  successful  in  large  gummata. 

LITERATURE 

Bowlby,  Trans.  Path.  Soc,  1897,  p.  128. 
Carpenter,  Brit.  Journ.  Child.  Dis.,  1908,  p.  93. 
Delamore,   Gaz.  des  Hop.,  1900,  p.  553. 
Guthrie,  Lancet,  Feb.  27  and  March  13,  1897; 

Brit.  Journ.  Child.  Dis.,  1908,  p.  90. 
Israel,  Deuts.  med.   Woch.,  1892,  No.   1. 
Nador,  Deuts.  med.  Woch.,  1911,  p.  838. 
Stoerk,  Wien.  med.  Woch.,  1901. 
Sutherland  and  Thomson  Walker,  Brit.  Med.  Journ., 

April  25,  1903. 


CHAPTER  XVII 
RENAL  CALCULUS 

Stones  formed  in  the  kidney  may  remain  lodged  in  a  calyx  or 
in  the  pelvis,  or  they  may  enter  the  ureter  and  either  become 
arrested  in  the  duct  or  pass  into  the  bladder. 

Etiology. — A  urinary  calculus  is  an  agglomeration  of  crystals 
held  together  by  a  cement  substance.  In  discussing  the  origin 
of  calculi  it  is  therefore  necessary  to  consider  (1)  the  presence  of 
crystals  in  the  urine,  and  (2)  the  nature  and  origin  of  the  cement 
substance. 

1.  Presence  of  crystals  in  the  urine. — The  crystals  which 
form  calculi  are  the  crystalline  form  of  substances  normally  found 
in  solution  in  the  urine.  The  urine  is  something  more  than  a 
watery  solution  of  certain  salts,  for  it  has  the  power  of  holding  a 
greater  proportion  of  some  salts  in  solution  than  has  distilled 
water.  Thus,  uric  acid  is  soluble  to  a  greater  extent  in  urine  than 
in  distilled  water.  This  property  is  due  to  the  presence  of  certain 
colloid  bodies  such  as  mucin  and  urochrome. 

Precipitation  in  crystalline  form  of  certain  salts  occurs  as  a 
result  of  their  presence  in  excessive  quantities,  or  of  changes  in  re- 
action, or  of  bacterial  action.  In  this  way  crystals  of  phosphates, 
of  oxalate  of  lime,  and  of  uric  acid  are  deposited  in  the  urine. 

Phosphaturia  may  be  due  to  general  or  to  local  causes  which 
are  described  elsewhere.  The  form  of  phosphatic  deposit  in  the 
urine  which  is  important  in  the  formation  of  stone  is  that  caused 
by  bacterial  decomposition  of  the  urine.  This  occurs  in  chronic 
septic  pyelonephritis,  and  "  secondary  calculi "  are  formed. 

In  oxcduria  (p.  47)  there  is  a  deposit  of  crystals  of  calcium 
oxalate,  and  this  condition  is  frequently  associated  with  the  deposit 
of  uric  acid.  The  oxalates  in  the  urine  are  derived  partly  from 
the  food  and  partly  from  the  tissues,  and  are  kept  in  solution 
in  the  urine  by  acid  phosphates  of  sodium  and  magnesian  salts. 
Oxaluria  is  due  less  to  the  ingestion  of  excessive  quantities  of 
oxalates  in  the  food  than  to  derangements  of  digestion  and 
assimilation. 

249 


250  THE   KIDNEY  [chap. 

The  uric  acid  in  the  urine  is  derived  from  the  nucleins  of  the 
food  and  as  a  product  of  metabohsm  in  the  body.  The  conditions 
which  produce  an  increase  and  deposit  of  uric  acid  are  excess  of 
nitrogenous  foods  and  alcohol,  want  of  oxidation  from  leading  a 
sedentary  life,  hepatic  congestion,  gout,  and  the  gouty  form  of 
diabetes  mellitus.  Uric  acid  is  held  in  solution  by  the  salts  of  the 
urine  as  urates  and  by  the  pigmentary  colloids.  Deposit  of  uric 
acid  may  be  due  to  an  increase  in  the  total  quantity,  or  to  a  re- 
duction of  the  salts  or  pigment,  or  to  an  increase  in  the  acidity 
of  the  urine.  Uric  acid  is  excreted  in  the  form  of  urates  of  sodium, 
potassium,  calcium,  and  magnesium,  which  are  soluble  in  the 
urine.  If  the  urine  is  highly  concentrated  the  urates  are  deposited 
when  the  fluid  cools.  This  is  frequently  observed  after  excessive 
exercise,  in  tropical  heat,  in  fevers,  and  in  derangements  of  the 
liver  and  stomach. 

In  infants  "renal  infarcts"  composed  of  urates  and  uric  acid 
are  frequently  found  in  the  convoluted  tubules  soon  after  birth. 
These  disappear  when  the  flow  of  urine  is  fully  established.  They 
may  remain  to  form  the  nucleus  of  a  true  calculus. 

Cystinuria  is  an  hereditary  and  family  disease,  due  to  an 
abnormality  in  metabolism.  The  tissues  are  unable  to  complete 
the  oxidation  of  the  cystin  normally  formed  in  the  breaking  down 
of  protein.  Cystin  contains  25-5  per  cent,  of  sulphur,  and  in 
cystinuria  about  0-5  grm.  is  excreted  in  twenty-four  hours.  The 
health  is  not  impaired. 

The  precipitation  of  these  bodies  in  crystalline  form  is  not  alone 
sufiicient  to  form  a  calculus,  but  it  is  one  factor  in  the  production 
of  a  calculus. 

2.  Colloid  substances. — The  second  essential  factor  in  the 
formation  of  a  stone  is  the  presence  of  a  colloid  cement  substance. 
Colloid  bodies  are  present  in  the  normal  urine  in  the  form  of  mucin 
and  urochrome.  But  these  colloid  bodies  are  not  sufficient  to 
produce  a  stone.  Phosphaturia,  oxaluria,  etc.,  may  be  present  for 
years  without  a  calculus  being  formed.  In  cystitis  mucin  is  in 
excess,  and  large  quantities  of  triple  phosphates  are  thrown  down 
and  are  entangled  in  the  masses  of  mucin.  Plugs  of  this  material 
are  formed  and  are  passed  in  the  urine.  They  are  of  slimy  con- 
sistence, rarely  approaching  the  firmness  of  putty,  and  are  readily 
broken  up  between  the  fingers.  These  masses  do  not,  even  after 
the  lapse  of  months,  form  calculi. 

Schade  has  pointed  out  that  the  colloids  found  in  the  urine 
vary  in  nature.  They  may  be  "  reversible,"  for,  after  once  having 
passed  out  of  solution,  they  may  under  changed  conditions  of 
reaction,   etc.,   be  again  taken  into   solution.     Or  they  may  be 


XVII]  RENAL   CALCULUS:    ETIOLOGY  251 

"  irreversible,"  i.e.  when  once  precipitated  they  are  insoluble.    For 
the  formation  of  a  calculus  an  irreversible  colloid  is  necessary. 

Irreversible  colloids  do  not  occur  in  normal  urine,  but  are 
present  in  pathological  conditions.  Fibrin,  formed  from  fibrinogen, 
is  the  characteristic  representative  of  the  group  of  irreversible 
colloids.  It  appears  in  the  urine  as  a  result  of  haemorrhage  or 
of  inflammation  ;  it  occurs  also  in  a  very  rare  state  of  the  urine 
known  as  fibrinuria.  Schade  suggests  that  fibrinuria  in  a  very 
slight  form  may  occur  more  frequently  than  is  supposed.  It  is 
of  extreme  interest  to  note  that  bodies  having  the  shape  and 
appearance  of  calculi,  but  composed  almost  wholly  of  fibrin,  are 
sometimes  found  in  the  renal  pelvis  or  in  the  bladder.  The  ultimate 
cause  which  leads  to  the  presence  of  fibrin  or  other  irreversible 
colloids  in  the  urine  where  there  has  been  no  injury  is  at  present 
doubtful.  The  passage  of  quantities  of  crystals  in  the  urine  may 
itself  excite  mild  inflammation  in  the  urinary  tract.  It  is  known 
that  bacteria  and  toxins  are  constantly  being  absorbed  into  the 
circulation  from  the  throat  and  bowel  (especially  in  constipation), 
and  excreted  by  the  kidneys,  without  causing  gross  inflammatory 
changes,  but  it  is  not  unhkely  that  lesser  degrees  of  reaction  may 
be  induced. 

General  factors  in  etiology. — Heredity  plays  an  undoubted 
although  ill-defined  role  in  the  production  of  renal  calculus.  A 
history  of  calculous  disease  in  one  or  several  members  of  the 
patient's  family  in  different  generations  can  frequently  be  obtained. 
I  have  twice  had  under  my  care  a  father  and  son  afflicted  with 
renal  calculus.  That  this  is  not  due  ^to  external  influences  is 
shown  by  the  record  given  by  Leroy  d'Etiolles  of  eight  brothers 
suffering  from  stone,  who  lived  in  different  parts  of  Europe 
under  varying  conditions  of  hygiene  and  climate.  Heredity  is 
most  marked  in  uric-acid  calculus. 

Renal  calculi  occur  most  frequently  in  mid-adult  life.  Watson 
found  the  average  age  in  fifty-four  cases  was  38  years.  Opera- 
tions for  renal  calculus  is  rarely  necessary  in  children  under  10,  or 
iii  adults  over  60.  It  is  not  unusual,  however,  in  young  adults  to 
obtain  a  history  of  symptoms  dating  back  to  infancy  or  childhood. 
Men  are  slightly  more  liable  than  women.  Each  kidney  is  afiected 
with  equal  frequency.  In  the  later  stages  renal  calculi  are  usually 
bilateral,  but  at  an  early  period  they  are  unilateral.  Kiister  found 
bilateral  renal  calculi  in  11-78  per  cent.,  and  Israel  in  27  per  cent, 
of  operated  cases.  With  earlier  diagnosis  by  the  X-rays  these 
figures  may  now  be  further  reduced.  Post-mortem  e\adence, 
representing  the  final  stage  of  the  disease,  shows  that  calculi  are 
bilateral  in  over  50  per  cent,  of  cases. 


252  THE   KIDNEY  [chap. 

Food  and  drinking-water  play  an  important  part  in  the  pro- 
duction of  calculi.  The  effect  of  foods  on  the  increase  in  uric 
acid  and  oxalates  in  the  urine  has  already  been  mentioned.  Hard 
water  influences  the  production  of  calculus  by  supplying  an  ex- 
cessive quantity  of  calcium  salts.  Deposits  of  calcium  oxalate  or 
calcium  phosphate  in  the  urine  are  thus  encouraged.  Sedentary 
habits  causing  deficient  oxidation  of  nitrogenous  bodies  and 
inaction  of  the  liver  increase  the  uric-acid  output  in  the  urine 
and  predispose  to  calculus. 

Calculous  disease  is  very  irregularly  distributed.  It  is  common 
in  India,  and  occurs  both  in  Europeans  and  in  natives — ^in  the 
latter  more  frequently  than  in  the  former.  Here  the  effect  of 
tropical  climate  is  held  to  influence  the  production  of  stone.  The 
concentrated  urine  is  believed  to  cause  such  irritation  as  will  pro- 
duce the  colloid  necessary  for  the  formation  of  a  calculus. 

In  Europe,  Central  Russia,  Hungary,  Holland,  Italy,  Northern 
Germany,  Western  France,  and  the  Eastern  Counties  of  England 
calculus  is  especially  prevalent.  According  to  Preindlsberger, 
stone  cases  in  Bosnia  and  Herzegovina  are  confined  to  a  strip  of 
land  which  for  the  most  part  consists  of  hmestone  of  the  Dinaric 
Alps,  and  in  this  area  Christians  are  much  more  frequently  affected 
than  Mohammedans.  On  the  authority  of  Kiister,  Jews  are  stated 
to  be  more  frequently  affected  than  other  races  in  North  Germany. 
The  reason  for  this  geographical  distribution  is  unknown.  Neither 
climate,  geological  formation  such  as  chalky  soil  and  drinking- 
water,  nor  race  is  a  common  factor.  In  secondary  phosphatic 
calculi,  stasis  of  urine  from  obstruction  is  frequently  present  and 
is  an  important  predisposing  cause. 

Structure  and  chemical  composition. — In  the  centre  of  the 
calculus  is  a  nucleus,  and  disposed  around  this  are  concentric 
laminse  of  varying  composition.  In  infants  the  nucleus  usually 
consists  of  urate  of  ammonia,  in  adults  of  uric  acid,  and  after  the 
age  of  40  of  oxalate  of  lime.  Rarely  a  fragment  of  blood  clot 
forms  the  nucleus ;  and  the  ova  of  bilharzia  have  been  found. 
The  laminse  are  formed  of  crystals  or  amorphous  material  bound 
together  by  cement  substance.  Alternate  layers  of  uric  acid 
and  oxalate  of  lime,  or,  if  the  urine  is  alkaline,  a  covering  of  triple 
phosphates  and  calcium  carbonate,  are  deposited. 

The  substances  that  enter  into  the  composition  of  renal  calculi 
are — 

Uric  acid. 

Ammonium  and  sodium  urate. 

Calcium  oxalate. 

Calcium  phosphate. 


XVIl] 


RENAL   CALCULUS:   STRUCTURE 


253 


Calcium  carbonate. 

Ammonium  and  magnesium  phosphate. 

Cystin. 

Xanthin. 

Indigo. 

Blood. 
The  phosphates  and  carbonates  are  found  in  alkaline  urines,  all 
the  others  in  acid  urines. 

Calculi  are  said  to  be  primary  when  they  arise  in  a  previously 
healthy  urinary  tract,  and  secondary  when  they  result  from 
changes  in  the  urine  due  to  infective  processes. 

They  are  rarely  composed  of  one  salt.  In  the  great  majority 
of  stones  several  substances  are  present.  Thus,  uric  acid  and 
calcium  oxalate  frequently  occur  in  alternating  layers  in  the  same 
calculus.  If  the  urine  becomes  alkaline  a  deposit  of  phosphates 
takes  place  on  the  surface  of  the  stone. 

Hitherto  it  has  been  customary  to  name  calculi  uric-acid  or 
uratic  when  these  bodies  were  present,  without  reference  to  the 
possibility  that  they  might  form  only  a  small  fraction  of  the  total 
calculus.  In  this  way  uric-acid  calculi  have  been  looked  upon 
as  being  much  more  common  than  any  other  form  of  calculus. 
Beneki  found  that  479  out  of  649  urinary  calcuh  in  the  Hunterian 
Museum,  or  about  74  per  cent.,  contained  uric  acid  or  urates,  and 
Dickinson  found  about  the  same  proportion  (70  per  cent.)  in  renal 
calculi.  In  calculi  removed  by  operation,  however,  where  minute 
fractions  of  salts  are  not  taken  into  account,  oxalate  of  lime  is 
much  the  most  frequent  component.  Of  77  calculi  collected  by 
Morris  the  composition  was  as  follows  : — 

Oxalate  of  lime     . .  . .         34         . .  . .         44-15  per  cent. 


Uric  acid     . . 

17 

2207 

Phosphates . . 

Cystin 

Calcium  carbonate 

13 
2 
1 

16-88 
2-6 
1-3 

Mixed  calculi 

10 

13-0 

77 

Oxalate  calculi  are  therefore  much  more  common  than  was  at 
one  time  believed.  Moore  has  corroborated  this  view  from  an 
analysis  of  21  renal  and  ureteral  calculi  removed  by  operation, 
all  of  which  contained  calcium  oxalate  in  large  amount,  in  more 
than  two-thirds  of  them  over  70  per  cent. 

Eenal  calculi  vary  in  appearance  and  consistence  according 
to  their  chemical  composition. 

Oxcdate-of-lime  calculi  are  usually  single.  They  are  very  hard, 
dark-brown  or  black,  with   a   nodulated  surface  or  covered  with 


254  THE   KIDNEY  [chap. 

fine  crystals  or  coarse,  clear,  crystalline  spicules.  Oxalate-of-lime 
calculi  sometimes  take  the  form  of  multiple  small  polished  brown 
or  black  seed-like  bodies.  They  are  laminated  on  section,  and 
are  found  in  acid  urine.  Uric-acid  calculi  are  single  or  multiple, 
hard,  smooth,  sometimes  highly  poHshed,  and  yellow  or  red-brown 
in  colour.  They  occur  in  acid  urine,  and  show  a  laminated  cut 
surface.  Calculi  composed  of  ammonium  and  sodium  urate  occur 
in  children.  They  are  small,  soft,  and  friable,  and  of  a  pale  fawn 
colour.  Calcium-phosphate  calculi  are  greyish-white,  hard,  with 
an  irregular  and  sometimes  crystalline  surface.  They  may  become 
coated  with  triple  phosphate.  On  section  they  are  laminated. 
They  are  found  in  a  neutral  or  slightly  alkaline  urine.  Calculi  of 
mixed  phosphates  (fusible  calculus)  are  whitish-grey,  mortar-like, 
friable  masses,  which  increase  in  size  with  great  rapidity.  There 
is  no  lamination.  They  may  be  covered  with  crystals  of  triple 
phosphate.  They  occur  in  ammoniacal  urine.  Cystin  calculi  are 
yellow,  smooth,  and  soft.  After  removal  they  assume  a  greenish, 
waxy  appearance.  On  section  they  have  a  radiating  structure. 
They  are  very  rare.  Xanthin  calculi,  too,  are  very  rare.  They  form 
smooth,  hard,  reddish,  cinnamon-coloured  stones.  Indigo  calculi 
are  also  very  rare,  only  two  examples  being  known.  The  calculus  is 
blue-black  with  a  grey  polished  surface  on  section,  and  it  leaves 
a  blue  mark  on  white  paper.  Blood  calculi  or  fibrin  calculi  are  of 
extreme  rarity.  In  1907  I  explored  the  left  kidney  of  a  woman 
aged  58  for  two  attacks  of  hsematuria,  pain,  and  undue  mobility 
of  the  organ.  In  the  renal  pelvis  were  packed  six  greyish-brown 
masses,  the  size  of  a  small  marble,  shaped  like  gall-stones  with 
facets.  They  had  a  putty-like  consistence,  and  became  darker 
brown  on  exposure  to  air.  On  section  the  masses  were  laminated 
and  composed  of  fibrin  coated  on  the  surface  with  blood  and  some 
crystals  of  uric  acid.  Gage  and  Beal  have  collected  a  few  similar 
cases  from  the  literature. 

Size,  shape,  and  number. — Most  calculi  removed  by  operation 
are  single,  but  it  is  not  unusual  to  find  multiple  calcuU.  (Plate  18 
and  Fig.  57.)  As  many  as  200  have  been  removed  from  a  kidney. 
Two  or  three  small  round  calculi  may  be  formed  in  a  small  pouch 
of  the  pelvis  or  calyx,  and  passed  down  the  ureter  at  intervals,  and 
this  process  may  be  repeated  at  intervals  during  many  years. 
Slightly  larger  solitary  calculi  in  the  pelvis  are  rounded  or  oval 
and  are  freely  movable,  or  they  may  be  wedge-shaped  and  fixed. 
Larger  calculi  are  moulded  into  an  exaggerated  form  of  the  renal 
pelvis  and  have  sometimes  fixed  branches  which  fill  the  calyces, 
or  there  may  be  facets  with  which  smaller  calcuh  that  lie  in  the 
calyces  articulate. 


Multiple  calculi  of  kidney.     (P.  254.) 


Plate  18. 


XVIl] 


RENAL  CALCULUS 


255 


Very  large  calculi  are  sometimes  found.  Shield  records  one  of 
1|  lb.  having  a  circumference  of  10  in.,  and  Lc  Dentu  one  weighing 
over  3  lb. 

Small  calculi  usually  lie  in  the  renal  pelvis,  or  they  may  be 
wedged  into  a  calyx.  The  communication  with  the  pelvis  of  a 
calyx  containing  a  calculus  may  be  very  narrow.  A  large  calculus 
is  lodged  in  the  pelvis,  and  the  branches  in  the  calyces.     A  branch 


Fig.  57. — Calculi  removed  from   one  kidney. 

may  have  a  neck  which  is  firmly  gripped  in  the  narrow  commu- 
nication between  pelvis  and  calyx. 

It  is  said  that  a  calculus  has  rarely  been  found  embedded  in 
the  substance  of  the  kidney  and  unconnected  with  the  calyces 
I  have  not  met  with  such  a  case. 

Changres  in  the  kidney.  1.  Aseptic  lesions,  i.  Diathetic 
nephritis. — Albarran  has  shown  that  all  calculous  kidneys  are 
found,  on  microscopical  examination,  to  bear  the  lesions  of 
nephritis.  Even  when  the  organ  appears  normal  to  the  naked  eye, 
microscopical  examination  shows  that  chronic  nephritis  is  present. 

These  lesions  depend  upon  the  original  cause  of  the  lithiasis, 


256  THE   KIDNEY  [chap. 

and  when  once  the  calculus  is  formed  they  are  aggravated  by 
its  presence. 

Diathetic  nephritis  consists  of  a  diffuse  nephritis  probably 
commencing  in  epithelial  lesions  and  accompanied  by  interstitial 
nephritis.  At  first  the  kidney  may  appear  normal  or  increased 
in  size.  Later  it  contracts  and  becomes  granular.  The  capsule 
becomes  adherent,  and  small  cysts  form.  The  condition  is  that 
of  granular  contracted  kidney. 

ii.  Lesions  consecutive  to  the  presence  of  a  calculus  in  the  kidney 
or  renal  pelvis. — ^When  the  calculus  reaches  a  certain  size  or  lies 
in  a  position  to  cause  obstruction,  changes  in  the  kidney  are 
added  to  those  already  existing.  The  following  conditions  may 
be  found : — 

(a)  The  kidney  appears  almost  normal.  There  is  a  slight  con- 
densation of  the  fatty  capsule,  the  fibrous  capsule  is  shghtly  more 
adherent,  and  the  organ  appears  a  little  large.  The  pelvis  con- 
tains one  or  several  stones.  There  is  a  little  thickening  of  the 
pelvic  wall,  and  slight  distension  of  the  calyces  and  pelvis.  The 
microscope  shows  the  lesions  described  by  Albarran  as  nephrite 
diathesique. 

(b)  There  is  advanced  interstitial  nephritis  with  atrophy,  or 
occasionally  the  kidney  may  have  previously  been  enlarged  as  a 
hydronephrosis  and  then  have  shrunk  till  it  is  small  and  atrophied. 

(c)  Perinephritis  leading  to  a  great  increase  in  the  perirenal 
fat  has  already  been  described.  In  the  majority  of  cases  it  results 
from  calculus  of  the  kidney,  and  may  be  found  either  in  aseptic 
or  in  septic  calculus.  The  kidney  may  be  surrounded  by  a  large 
mass  of  adherent  fibro-fatty  tissue.  The  circumrenal  fatty  tissue 
invades  the  hilum  and  spreads  along  the  blood-vessels  into  the 
substance  of  the  kidney,  compressing  and  eventually  completely 
destroying  it.     (Plate  19.)     The  kidney  retains  its  normal  contour. 

(d)  Hydronephrosis  is  a  comparatively  common  complication 
of  renal  calculus,  and  results  from  the  impaction  of  a  small  cal- 
culus at  the  outlet  of  the  renal  pelvis.  Rarely  a  calculus  may 
plug  the  outlet  of  a  single  calyx  or  of  one  branch  of  a  dichotomous 
pelvis,  and  a  partial  hydronephrosis  results. 

Hydronephrosis  due  to  calculous  impaction  differs  from  other 
forms  in  the  presence  of  uretero-pyelitis  caused  by  the  irritation 
of  the  calculus.  This  leads  to  thickening  and  narrowing  of  the 
duct  at  a  later  time.  In  calculous  hydronephrosis  also  the  aseptic 
nephritis  above  described  is  already  present  when  dilatation  com- 
mences, and  changes  in  the  kidney  substance  are  much  more 
advanced  in  the  earlier  stages  of  distension  than  in  other  forms  of 
hydronephrosis. 


Renal  calculus ;  dilatation  of  renal  pelvis  and  pyelitis  :    invasion  and 
destruction    of  kidney    by    hypertrophy    of  fat    in    renal    sinus. 

(P.  256.) 


Plate  19. 


XVII]         RENAL   CALCULUS:  PATHOLOGY  257 

2.  Infective  lesions. — Infection  of  the  calculous  kidney  may 
take  place  bv  the  blood  stream  {Juetnatogenous  infection),  or  the 
infection  may  ascend  the  urinary  tract  after  the  passage  of 
instruments  {ascending  injection). 

In  the  great  majority  of  cases  the  infection  is  haematogenous, 
and  has  taken  place  before  any  instrument  has  been  passed. 
Hematogenous  infection  may,  however,  be  supplemented  by  an 
ascending  infection  after  the  passage  of  an  infected  instrument. 
The  infection  may,  in  quiescent  calculus,  obscure  the  presence  of 
the  stone.  On  the  other  hand,  secondary  calculi  may  develop  in 
an  infected  kidney. 

i.  Pyelonephritis. — Acute  pyelonephritis  without  obstruction 
does  not  occur  frequently  when  calculi  are  present.  Subacute  and 
chronic  septic  pyelonephritis  are  much  more  common.  Pyelitis 
is  very  seldom  fomid  without  nephritis  being  superadded. 

ii.  Pyonephrosis  and  uro-pyonephrosis. — Calculous  pyonephrosis 
is  much  more  common,  and  may  reach  a  large  size.  In  the  dilated 
calyces  calculi  of  varpng  sizes  Ue,  and  may  be  tightly  grasped  by 
the  narrow  neck  of  the  calyx.  (Fig-  58.)  At  the  outlet  of  the 
pelvis  lies  the  plugging  calculus,  which  may  be  of  moderate  size, 
and  is  often  roughly  conical  in  shape.  Many  calculi  may  be  present, 
and  there  is  sometimes  a  quantity  of  mortar-like  secondary  phos- 
phatic  deposit. 

In  uro-pyonephrosis  the  content  is  either  cloudy  or  purulent 
urine. 

iii.  Perinephritis  and  perinephritic  abscess. — Fatty  and  fibro- 
fatty  perinephritis  are  more  frequent  and  extensive  in  septic  cal- 
culi than  in  aseptic.  Large  masses  may  thus  be  produced,  and 
dense  adhesions  with  the  peritoneum,  bowel,  vena  cava,  and  other 
neighbouring  structures  are  formed,  which  render  removal  of  the 
whole  mass  dangerous.  The  kidney  may  be  easily  stripped  from 
its  fibrous  capsule  inside  the  fatty  mass.  Suppurative  peri- 
nephritis sometimes  develops,  and  a  calculus  may  be  found  in  the 
abscess,  ha\nng  escaped  from  the  kidney. 

Rupture  of  the  abscess  has  led  to  the  discharge  of  a  calculus 
on  the  surface  of  the  buttock  or  in  Scarpa's  triangle. 

iv.  Malignant  growth  of  the  renal  pelvis. — In  a  small  number 
of  cases  a  calculus  has  been  found  coexisting  "with  a  malignant 
growth  of  the  renal  pelvis,  and  in  these  cases  the  new  growth  is 
believed  to  have  resulted  from  the  prolonged  irritation  of  the 
calculus.  Drew  found  calculi  in  4  out  of  8  cases  of  villous 
growth  of  the  renal  pehds  collected  from  the  Hterature.  Others 
have  been  recorded  by  Israel,  Hartmann,  Kundrat,  Ransohoff, 
and  Porter. 


258 


THE   KIDNEY 


[chap. 


3.  Lesions  of  the  second  kidney. — Of  78  cases  collected 
by  Legueu,  there  were  lesions  of  the  second  kidney  in  half  the 
number.     In  21  cases  there  was  sclerosis  or  atrophy. 

Of  22  cases  of  death  from  anuria  after  operation  for  renal  cal- 
culus, I  found  that  the  second  kidney  contained  calculi  in  12,  and 
that  hydronephrosis  had  resulted  in  2  of  these,  pyonephrosis  in  3, 


Fig.  58. — Calculous  pyonephrosis  with  dilatation  of  ureter. 

and  atrophy  in  2.  There  was  atrophy  without  calculus  of  the 
second  kidney  in  4,  hydronephrosis  in  2,  amyloid  degeneration  in 
1,  interstitial  nephritis  in  1,  and  fatty  degeneration  in  2  cases. 

i.  Compensatory  hypertrophy  of  the  second  kidney  occurs  if 
the  parenchyma  of  the  calculous  kidney  is  widely  destroyed. 

ii.  Stone  is  present  in  the  second  kidney  in  over  50  per  cent,  of 
■cases  in  late  stages,  but  in  only  about  11  per  cent,  in  the  early  stage. 


XVII]  RENAL  CALCULUS :  SYMPTOMS  259 

iii.  Interstitial  nephritis  is  present  in  many  cases  even  where 
the  kidney  appears  healthy  to  the  naked  eye. 

iv.  Ascending  pyelonephritis  occurs  as  a  fatal  complication  in 
some  cases  where  cystitis  is  present.  It  may  follow  an  operation 
for  calculus  of  the  bladder. 

Symptoms. — In  the  majority  of  cases  renal  calculus  gives 
rise  to  a  distressing  train  of  symptoms  from  which  the  patient 
demands  relief. 

Quiescent  calculus. — Occasionally  a  calculus  lies  quiescent 
for  many  years,  and  the  patient  is  unaware  of  its  existence.  Two 
varieties  of  quiescent  calculus  have  come  under  my  observation. 
In  one  variety  there  are  no  symptoms  to  attract  the  attention  of 
the  patient ;  there  may  have  been  symptoms  during  childhood, 
or  no  symptoms  at  any  time.  In  the  second  variety  there  are 
persistent  symptoms  of  cystitis,  but  none  of  renal  disease.  In  a 
man  aged  45,  from  whom  I  removed  the  stones  shown  in  Fig.  57, 
there  had  been  cystitis  for  twenty-seven  years,  with  attacks  of 
hsematuria  on  exertion,  but  no  pain  or  other  symptom  pointing 
to  the  kidney  until  a  few  weeks  before  I  saw  him. 

There  are  cases  of  unsuspected  calculi  with  high  tempera- 
ture and  great  mental  prostration,  which  present  the  features  of 
severe  acute  pyelonephritis  due  to  the  bacillus  coli.  When  the 
acute  symptoms  have  subsided,  calculi  are  discovered  in  the 
kidney. 

The  cardinal  symptoms  of  renal  calculus  are  pain  and  heema- 
turia. 

Pain. — Pain  is  present  in  over  70  per  cent,  of  cases,  and  is  felt 
in  the  posterior  renal  area  at  the  costo-muscular  angle.  If  the 
pain  is  severe  it  can  also  be  felt  at  a  spot  on  the  front  of 
the  abdomen  about  li  in.  below  and  internal  to  the  tip  of 
the  9th  rib. 

There  are  three  varieties  of  pain  in  renal  calculus — (1)  fixed 
renal  pain,  (2)  renal  colic,  and  (3)  referred  pain. 

1.  Fixed  pain. — The  pain  is  felt  in  the  positions  described 
above.  It  is  a  constant  dull  ache,  of  varying  intensity.  It  is 
increased  by  movement  or  jarring.  Walking,  especially  over 
rough  ground,  jumping,  driving,  or  motoring,  and  especially  horse- 
riding  and  bicycling,  aggravate  the  pain  and  may  be  the  cause  of 
intense  suffering.  The  patient  is  most  comfortable  in  bed,  but 
even  in  the  recumbent  position  must  turn  carefully,  and  may  be 
unable  to  sleep  on  the  diseased  side  when  the  pelvis  is  inflamed 
(Fen wick).  In  walking  the  patient  may  bend  the  body  towards 
the  diseased  side ;  in  lying,  the  thigh  may  be  flexed  to  relax  the 
psoas  muscle.     Extreme  flexion  of  the  body  may  produce  great 


260 


THE   KIDNEY 


[chap. 


pain.  I  saw  an  actor  who,  with,  a  stone  in  his  right  kidney,  had 
to  give  up  playing  the  part  of  a  hunchback  on  account  of  the 
intolerable  pain  he  suffered  on  bending  the  body. 

Where  the  renal  pelvis  is  inflamed  the  pain  becomes  intense 
and  is  provoked  by  sHght  movements.  The  pain  corresponds  in 
some  degree  to  the  size  and  character  of  the  stone,  A  large 
stone  gives  little  or  no  severe  pain,  but  may  cause  dull  aching.  A 
small  stone  fixed  in  a  calyx  is  unlikely  to  give  much  pain. 
A  small  round  or  oval  stone  with  rough  crystalline  surface  free 
in  the  renal  pelvis  is  accompanied  by  the  most  severe  pain. 

2.  Renal  colic. — Renal  colic  commences  in  the  anterior  or 
posterior  renal-pain  area  (Fig.  59)  and  shoots  downwards,  following 
the  line  of  the  ureter  on  the  surface  of  the  body,  or  a  line  lower 


Fig.  59. — Line  of  right  renal  colic  :   anterior  and  posterior 
renal-pain  areas  in  renal  calculus. 

down  almost  at  the  level  of  Poupart's  ligament.  The  pain  passes 
to  the  external  abdominal  ring  ;  it  may  end  there,  or  may  be  con- 
tinued along  the  cord  into  the  testicle  of  the  corresponding  side, 
or  may  shoot  along  the  urethra  to  the  tip  of  the  penis.  It  may 
radiate  down  the  front  of  the  thigh,  or  along  the  sciatic  nerve, 
or  across  the  abdomen.  Renal  colic  never  shoots  directly  across 
or  upwards. 

An  attack  of  renal  colic  is  usually  initiated  by  some  exertion 
or  jar,  such  as  a  stumble,  or  by  a  sudden  twist  or  turn  in  bed; 
or  it  may  commence  during  sleep.  The  patient  sits  writhing  or 
rolls  in  agony,  the  face  is  pale,  the  skin  clammy  and  sweating, 
and  vomiting  frequently  occurs.  The  testicle  on  the  painful  side 
is  retracted  and  intensely  tender.  The  abdominal  muscles  are 
rigid,  the  thigh  is  flexed. 

There  may  be  an  intense  and  urgent  desire  to  micturate,  and 


XVIl] 


RENAL  CALCULUS  :  PAIN 


261 


repeated  attempts  are  made  at  short  intervals.  The  quantity  of 
urine  secreted  during  an  attack  of  renal  colic  is  small,  and  no 
urine  may  be  passed  for  several  hours. 

If  unrelieved  by  treatment  the  attack  may  last  for  one  or  for 
several  hours.  It  frequently  ceases  quite  suddenly,  but  may 
subside  more  gradually.  After  an  interval  a  quantity  of  blood- 
stained urine  is  passed.  Some  hours,  or  several  days,  afterwards 
a  stone  may  be  passed  from  the  urethra  with  the  urine. 

3.  Referred  pain. — With  the  slighter  constant  pain  of  renal  cal- 
culus there  may  also  be  pain  referred  to  a  distant  part.    (Fig.  60.) 

Persistent  pain  is  occasionally  felt  in  the  sole  of  the  foot  or 


Fig.  60. — Areas  of  referred  pain  In  renal  calculus. 

heel.  It  is  felt  also  in  the  thigh  or  leg,  and  sometimes  in  the 
testicle  or  labium.  Karely  the  testicular  pain  is  more  prominent 
than  the  renal  pain,  and  may  even  exist  apart  from  it.  Bladder 
pain  with  frequent  and  urgent  micturition  is  sometimes  present 
in  renal  calculus  when  the  bladder  is  quite  healthy.  The  most 
important  reflex  pain  is  that  in  which  pain  is  referred  to  the  second 
kidney  (reno-renal  reflex).  Thornton  stated  that  pain  in  one 
organ  might  be  caused  by  a  calculus  in  the  other,  the  calculous 
kidney  being  painless.  This  has  frequently  been  disputed,  and 
it  has  been  held  that  aching  pain  may  be  felt  in  the  second 
kidney,  but  that  the  referred  pain  does  not  occur  in  a  healthy 
kidney  without  severe  pain  being  present  at  the  same  time  in 
the  diseased  organ.     I  have,  however,  seen  two  cases  where  the 


262  THE   KIDNEY  [chap. 

referred  pain  was  present  without  pain  in  the  calculous  kidney^ 
and  there  are  a  few  similar  cases  on  record. 

Since  the  introduction  of  the  X-rays  in  the  diagnosis  of  renal 
calculus  and  the  use  of  methods  for  the  examination  of  the  urine 
of  each  kidney,  this  question  of  referred  pain  has  lost  much  of 
its  importance. 

Haematuria. — Less  than  half  the  cases  of  renal  calculus  suffer 
from  hsematuria.  The  haematuria  is  not  usually  severe.  Blood 
corpuscles  are  often  found  with  the  microscope  in  cases  in 
which  the  blood  cannot  be  detected  with  the  naked  eye.  Hsema- 
turia  frequently  occurs  with  renal  colic,  and  may  continue  after 
the  coUc  has  ceased.  It  is  intimately  connected  with  movement 
and  exertion.  Occasionally  it  is  the  only  symptom.  There  may 
be  persistent  hsematuria  lasting  many  months,  and  unaffected  by 
rest  or  movement.  Like  pain,  it  is  more  apt  to  be  present,  and 
is  more  severe,  if  the  surface  of  the  stone  is  rough  and  irregular. 

Pyuria. — Pus  may  be  found  in  the  urine  in  small  amount 
from  slight  pyelitis  caused  by  the  irritation  of  the  calculus.  When 
the  kidney  becomes  infected  the  urine  is  cloudy  and  purulent 
to  the  naked  eye.  It  remains  acid,  and  the  pus  settles  in  a 
solid  layer  at  the  bottom  of  the  vessel.  Occasionally,  when  de- 
composition of  the  urine  has  taken  place  in  the  kidney,  the 
urine  passed  is  alkaUne  and  decomposing. 

Other  changes  in  the  urine. — HyaHne  casts  and  an  exces- 
sive quantity  of  urine  may  be  present  and  indicate  changes  in  the 
kidney  substance.  Crystals  of  calcium  oxalate  or  uric  acid  may 
be  present.  Phosphaturia  sometimes  occurs  with  renal  colic, 
without  other  changes  in  the  urine. 

In  the  later  stages  of  renal  calculus,  and  especially  where  both 
kidneys  are  the  seat  of  calculus  and  are  extensively  destroyed, 
the  urine  is  pale,  very  abundant,  and  of  low  specific  gravity,  and 
the  total  amount  of  urea  excreted  is  reduced.  Calculous  anuria 
will  be  discussed  later  (p.  278). 

Examination  of  the  kidney  and  ureter. — On  palpation 
of  the  abdomen  the  tips  of  the  fingers  may  detect  rigidity  of  the 
muscles  on  the  side  of  the  calculus. 

If  the  kidney  is  large  and  contains  many  stones,  it  forms  an 
abdominal  tumour.  If  the  patient  is  thin,  this  may  be  seen  in 
the  recumbent  position  as  a  prominence  in  the  lumbar  region  about 
the  level  of  the  umbilicus  or  a  Httle  below.  In  the  erect  posture 
the  prominence  disappears.  Palpation  shows  the  kidney  greatly 
enlarged  and  tender.  In  cases  in  which  the  patient  is  thin  and 
the  stones  are  large  and  covered  with  a  thin  layer  of  renal  tissue 
they  can  be  felt  on  palpation  as  irregular,  very  hard,  craggy  masses. 


XVII]        RENAL   CALCULUS:    CYSTOSCOPY  263 

and  grating  may  be  detected.  With  smaller  calculi  no  ejilarge- 
ment  of  the  kidney  is  felt  in  uncomplicated  cases.  The  kidney 
is,  however,  frequently  tender  on  palpation.  Jordan  Lloyd  has 
pointed  out  that  in  renal  calculus  a  stabbing  pain  may  be  elicited 
by  prodding  deeply  with  the  finger-tips  over  the  kidney. 

Cystoscopic  examination. — In  cases  in  which  hsematuria  is 
the  only  symptom  the  bleeding  is  seen  to  come  from  one  ureteric 
orifice,  and  the  observation  will  lead  to  the  further  examination 
and  eventual  exploration  of  that  kidney.  Wheii  the  urine  is 
purulent  it  can  be  seen  as  a  cloudy  efflux,  with  flakes,  coming  from 
one  ureteric  orifice.  The  efflux  is  ejected  vigorously,  and  is  rapidly 
repeated  in  pyelitis.  In  old-standing  pyelitis  due  to  calculus  or 
to  other  cause,  a  solid  pipe  of  pus  may  be  seen  to  be  slowly  expelled 
from  the  ureteric  orifice  and  glide  down  the  slope  of  the  ureteric 
ridge  like  a  worm,  or  break  up  into  short  segments.  The  appear- 
ance of  the  ureteric  orifice  gives  little  information  in  the  early  stage 
of  renal  calculus.  There  may  be  a  blush  of  congestion  and  inflam- 
mation round  the  ureteric  orifice  and  basal  cystitis  if  infection  of 
the  renal  pelvis  is  present.  In  long-standing  pyelitis  and  ureteritis 
from  calculus  or  other  cause  the  ureteric  orifice  is  round,  open, 
and  rigid. 

Should  nephrectomy  be  required,  the  ureter  of  the  second 
kidney  should  be  catheterized  and  the  urine  examined,  and  the 
function  of  the  kidney  tested. 

Radiography. — ^The  examination  of  the  kidneys  by  the 
X-rays  is  discussed  at  p.  38.     (Plate  20.) 

Course  and  complications. — Renal  calculus  may  exist  for 
many  years  and  give  rise  to  very  slight  inconvenience.  The 
symptoms  may  only  be  excited  by  movement,  and  the  patient 
gradually  curtails  his  exercise  until  he  lives  in  comparative  com- 
fort. Often,  as  the  stone  increases  in  size,  the  pain  and  attacks 
of  colic  diminish  and  occur  less  frequently.  The  general  health 
is  imaffected. 

Certain  complications  may  supervene  : 

1.  Migration  of  the  calculus. — The  passage  of  the  calculus 
along  the  ureter  is  accompanied  by  renal  colic,  and  has  already 
been  described  (p.  260). 

2.  Obstruction. — Obstruction  gives  rise  to  suppression  of 
urine  (calculous  anuria)  or  to  hydronephrosis. 

3.  Infection. — Infection  of  the  kidney  and  renal  pelvis  may 
precede  the  formation  of  a  calculus,  or  it  may  be  superimposed  on 
a  renal  calculus.  The  symptoms  due  to  the  infection  may  com- 
pletely obscure  those  caused  by  the  calculus,  which  may  remain 

'  unsuspected. 


264  THE   KIDNEY  [chap. 

The  infection  of  a  primary  calculus  is  almost  invariably  lisema- 
togenous.  It  may  take  the  form  {a)  of  pyelitis,  (6)  of  pyonephrosis, 
or  (c)  of  perinephritis. 

(a)  Calculous  pyelitis. — The  pain  of  the  calculus  becomes  greatly 
intensified,  and  the  kidney  is  very  tender  on  palpation,  without 
being  enlarged.  There  is  acid  pyuria  with  polyuria,  most  marked 
at  night. 

(6)  Pyonephrosis. — General  symptoms  become  evident.  There 
are  fever  and  emaciation.  The  kidney  is  enlarged  and  may  vary 
in  size,  the  variations  coinciding  with  an  increase  or  decrease  of 
pus  in  the  urine. 

(c)  Perinephritis  and  perinephritic  abscess.     {See  pp.  Ill,  112.) 

Prognosis. — An  untreated  renal  calculus  destroys  the  kidney 
in  which  it  is  lodged,  by  causing  sclerosis  and  atrophy  if  it  is 
aseptic,  and  by  suppuration  when  it  is  infected.  The  second  kidney 
becomes  affected  with  calculus  in  over  50  per  cent,  of  cases,  and 
is  eventually  the  seat  of  other  disease  in  a  still  larger  proportion. 
The  prognosis  of  renal  calculus  is  therefore  grave  unless  early 
operation  is  performed. 

Diagnosis. — Kadiography  has  revolutionized  the  diagnosis  of 
renal  calculus,  and  has  replaced  exploratory  operations  upon  the 
kidney  in  cases  of  suspected  calculus.  So  certain  and  precise  has 
this  means  of  diagnosis  become  in  the  hands  of  one  practised  in 
the  radiography  of  urinary  disease  that  there  is  a  tendency  to  use 
the  method  as  a  short  cut  to  diagnosis  without  duly  weighing 
the  symptoms.  Disappointment  and  a  tendency  to  cavil  at  the 
limitations  of  radiography  are  thus  engendered.  In  any  case  the 
proper  reading  of  a  radiographic  plate  of  good  quality  may  over- 
ride an  opinion  based  upon  symptoms ;  but  there  are  few,  if  any, 
cases  in  which  the  work  of  the  radiographer  is  not  rendered  easier 
and  more  valuable  by  a  knowledge  of  the  clinical  symptoms. 

Diagnosis  in  renal  calculus  presents  itself  as  a  number  of 
different  problems : 

1.  Cases  with  pain  and  hsematuria. — These  cases  are  some- 
times attended  with  difficulty  in  diagnosis. 

In  typical  cases  the  pain  predominates  and  the  haematuria 
occurs  "WT.th  the  pain.  Both  symptoms  are  initiated  or  increased 
by  movement  or  jarring.  The  passage  of  a  calculus  at  a  previous 
date  and  the  discovery  of  numerous  crystals  in  the  urine  are  of 
great  importance  in  the  diagnosis. 

In  movable  kidney  the  pain  is  also  closely  associated  with 
movement,  and  hsematuria,  although  it  is  rare,  may  occur.  The 
discovery  of  a  movable  kidney  should  not  be  accepted  as  exclud- 
ing calculus.     Radiography  should  be  used,   and  when  nephror- 


Fig.    1. — Shadows    of   large    branching    calculus   and    of  two    smaller   calculi 
(arrows)  in  kidney.     (Pp.  39,  263.) 

Fig.  2. — Shadow  of  calculi  in  right   kidney,  with   clear   field    in   left  kidney 
area.     (Pp.  39,   263.) 


Plate  20. 


XVII]  RENAL  CALCULUS:    DIAGNOSIS  265 

rhapliy  is  performed  the  kidney  should  be  thoroughly  examined 
for  stone. 

New  growths  of  the  kidney  with  haematuria  and  clot  colic  may 
resemble  renal  calculus.  In  such  cases  the  hsematuria  is  profuse, 
and  occurs  for  the  most  part  without  any  pain  ;  it  is  capricious 
in  its  onset  and  duration,  and  is  little  affected  by  rest  or  exercise. 
Colic  does  not  occur  apart  from  an  attack  of  hasmaturia.  It  co- 
incides with  the  sudden  disappearance  of  blood  from  the  urine, 
and  as  it  subsides  the  haemorrhage  reappears  and  ureteral  clots 
are  found  in  the  urine.  When  a  tumour  is  palpable  there  is  little 
difficulty,  for  its  characters  do  not  resemble  those  of  a  pyo-  or 
hydronephrosis,  and  the  condition  of  the  urine  is  different. 

In  cases  of  hsemorrhagic  nephritis  with  pain  there  may  be 
difficulty,  and  the  X-rays,  and  eventually  exploration  of  the  kidney, 
may  be  necessary  before  a  diagnosis  is  made. 

Patients  passing  a  highly  acid  concentrated  urine  with  uric- 
acid  or  calcium-oxalate  crystals  may  suffer  from  renal  colic,  fre- 
quent micturition,  and  hsematuria,  and  there  may  be  a  small 
quantity  of  mucus  or  even  a  trace  of  pus  in  the  urine.  In 
such  cases  the  symptoms  quickly  disappear  on  alkaline  diuretic 
treatment. 

2.  Cases  with  hsematuria  as  the  only  symptom. — These 
are  rare,  and  if  a  radiogram  is  not  obtained  the  presence  of  a  stone 
will  certainly  be  overlooked.  The  hsematuria  is  initiated  and 
increased  by  exertion.  New  growths  of  the  kidney  or  ureter  and 
hsemorrhagic  nephritis  are  the  conditions  most  likely  to  be  con- 
fused with  these  cases.  Very  rarely  portions  of  growth  are  found 
in  the  urine,  and  occasionally  numerous  tube  casts  and  albumin* 
may  be  met  with  in  the  intervals  between  attacks  of  hsenmturia 
in  nephritis.  In  rare  instances  cystoscopy  shows  a  portion  of 
gro^^'th  projecting  from  the  ureter. 

3.  Cases  with  pyuria  alone. — Tuberculous  disease  should  be 
excluded  by  examination  of  the  urine  for  the  tubercle  bacillus, 
and  by  cystoscopy.  Non-calculous  pyonephrosis  may  be  dis- 
tinguished by  the  history  of  an  initial  attack  of  acute  pyelo- 
nephritis or  other  cause. 

4.  Cases  with  renal  pain  as  the  principal  synnptom. — 
The  most  frequent  cause  of  renal  colic  is  calculus  in  the  kidney 
or  ureter,  but  it  may  also  be  due  to  the  passage  of  clots,  of  pus 
and  debris,  or  to  acute  ureteritis  without  a  calculus.  Hepatic 
colic  without  jaundice  is  said  to  resemble  renal  colic.  The  dis- 
tribution of  the  pain  is,  however,  different.  Hepatic  colic  com- 
mences over  the  gall-bladder  and  radiates  inwards  towards  the 
umbilicus  or  transversely,  while  renal  colic  frequently  commences 


266  THE  KIDNEY  [chap. 

in  the  posterior  renal  area,  and  always  shoots  downwards  either 
along  the  line  of  the  ureter  or  lower  down  in  the  groin.  It  passes- 
to  the  testicle  or  penis,  and  is  accompanied  by  retraction  of  the 
testicle. 

In  nephritis  dolorosa  there  is  renal  pain  which  may  be  severe. 
These  cases  were  at  one  time  described  as  renal  neuralgia.  It 
has  been  shown,  however,  by  Israel,  Albarran,  and  others  that 
microscopical  evidence  of  interstitial  nephritis  can  always  be 
obtained.  The  pain  is  seldom  so  severe  as  renal  cohc,  and  does 
not  radiate  along  the  ureter.  It  is  unaffected  by  movement. 
Where  hsematuria  is  present  also,  diagnosis  without  the  X-rays 
is  impossible. 

Raynaud  has  shown  that  the  crises  of  locomotor  ataxy  may 
be  indistinguishable  from  renal  cohc.  When  the  possibility  of 
such  a  cause  of  confusion  is  remembered,  the  only  difficulty  that 
can  arise  is  in  the  irregular  cases  of  tabes  {formes  frustes)  where  the 
classical  symptoms  may  be  wanting. 

Morris  has  recorded  cases  of  hysteria  in  which  difficulty  in 
diagnosis  from  renal  calculus  was  experienced.  Persistent  and 
sometimes  severe  pain  in  the  posterior  renal  area  is  sometimes 
caused  by  osteo-arthritis  of  the  lumbar  vertebrae.  Rigidity  of 
the  vertebral  column  and  the  appearance  of  lipping  of  the  ver- 
tebral bodies  in  a  radiogram  suffice  for  the  diagnosis. 

Calculus  in  the  ureter  causes  the  same  symptoms  as  renal 
calculus.  There  may,  however,  be  fixed  pain  at  some  spot  in 
the  line  of  the  ureter,  the  calculus  may  be  felt  per  rectum  or  per 
vaginam,  symptoms  of  vesical  irritation  may  be  very  marked,  and 
cystoscopy  may  show  changes  at  the  ureteric  orifice,  or  the  stone 
itself*may  be  seen  projecting  into  the  bladder. 

5.  Cases  with  symptoms  of  cystitis. — Persistent  cystitis 
may  be  present  with  latent  renal  calculus  and  lead  to  an  erroneous 
diagnosis.     I  have  already  referred  to  a  case  of  this  nature. 

The  diagnosis  is  made  by  the  examination  of  the  ureteric 
orifices  and  the  efflux  with  the  cystoscope,  and,  if  necessary,  by 
examination  of  the  urine  drawn  from  each  kidney  by  catheter. 
The  X-rays  may  show  a  large  stone  shadow. 

Even  where  a  stone  is  found  in  the  bladder  it  must  not  be  con- 
cluded that  no  stone  is  present  in  the  kidney,  and  radiography 
should  be  employed  to  exclude  renal  and  ureteric  calculi  in  these 
cases. 

Diagnosis  of  the  presence  and  health  of  a  second  kidney. 
— The  most  frequent  disease  of  the  second  kidney  is  calculus, 
and  a  clear  renal  area  in  a  radiographic  plate  will  exclude  this. 
In  addition  to  radiography  the  only  reliable  methods  of  diagnosis 


XVII]  RENAL  CALCULUS  :  DIET  267 

are  cystoscopy,  chromocystoscopy,  and  examination  of  the  urine 
drawn  from  the  second  kidney  by  means  of  the  ureteral  catheter. 

Treatment.  Prophylaxis. — This  consists  in  the  treatment 
of  oxaluria,  phosphaturia,  and  lithiasis,  and  the  removal  of 
local  conditions  which  may  assist  the  formation  of  stone.  The 
treatment  of  oxaluria  and  phosphaturia  has  been  discussed  else- 
where (pp.  48,  51).  The  local  conditions  which  assist  in  the 
formation  of  stone  are  urinary  infection  and  obstruction,  of  which 
the  treatment  is  considered  at  pp.  134  and  119.  When  a  patient 
passes  highly  acid  concentrated  urine  containing  uric-acid  crystals 
the  treatment  should  be  directed  to  reducing  any  excess  of  uric 
acid  which  may  be  derived  from  the  food,  assisting  the  complete 
metabolism  of  nitrogenous  bodies,  and  preventing  the  crystallization 
of  uric  acid  in  the  urine. 

Diet. — In  prescribing  diet  it  should  be  remembered  that 
there  is  a  daily  excretion  of  nitrogenous  bodies,  uninfluenced  by 
the  diet,  which  is  sufficient  to  form  calculi  should  other  conditions 
be  favourable.  The  patient's  strength  should  therefore  not  be 
reduced  by  too  rigid  a  regimen.  It  is  advisable  to  limit  the  quan- 
tities of  nitrogenous  foods,  but  it  is  unnecessary  to  prohibit  meat 
altogether.  Beef  and  mutton  should  be  taken  sparingly.  Cellular 
organs,  such  as  brain,  sweetbreads,  kidney,  and  liver,  contain 
excessive  quantities  of  nuclein,  from  which  uric  acid  is  derived, 
and  they  should  be  avoided.  White  meat  is  less  harmful  than 
red,  but  veal  and  pork  are  unsuitable  articles  of  diet.  Duck  and 
goose,  among  poultry,  and  high  game  should  be  avoided.  Fish 
may  be  taken,  except  salmon,  mackerel,  lobster,  and  crab.  Bread 
and  all  the  cereals,  all  the  roots  and  fruits  and  green  vegetables 
in  abundance,  and  salads,  should  form  part  of  the  diet.  Butter 
and  milk  and  eggs  may  be  taken. 

Tea  and  cofiee  should  be  avoided,  or  drunk  very  weak.  Sugar 
and  fats  are  harmful  and  should  only  be  taken  sparingly.  It  is 
better  to  avoid  wine  altogether,  but  should  it  appear  necessary  to 
permit  some  wine,  the  lighter  Moselle  and  white  French  wines,  or 
a  hght  claret,  should  be  selected.  Heavy  wines  such  as  Burgmidy, 
AustraHan  and  Calif ornian  wines  are  especially  harmful.  Port 
and  champagne  should  be  interdicted.  New  port  is  shghtly  less 
pernicious  than  old.  Whisky  may  be  allowed  in  very  small 
amount. 

Careful  attention  should  be  paid  to  regular  action  of  the  bowels, 
and  a  course  of  waters  containing  sulphates  of  soda  and  magnesia, 
such  as  Hunyadi  or  Friedrichshall,  is  beneficial.  Half  a  tumbler- 
ful or  more  should  be  taken  on  waking,  followed  by  a  tumblerful 
of  hot  water.     Courses  of  three  or  four  weeks,  with  intervals  of 


268  THE    KIDNEY  [chap. 

several    weeks,    m&y    be    prescribed.     Watson    speaks    highly    of 
calomel  given  in  doses  of  ^-^  gr.  at  night  for  a  week  at  a  time. 

The  urine  should  be  diluted  and  its  acidity  reduced.  A  large 
glass  of  hot  water  should  be  taken  in  the  early  morning  and  at 
night.  Aerated  distilled  waters,  such  as  Salutaris,  are  beneficial. 
Alkalis,  and  especially  those  with  a  diuretic  action,  are  useful. 
The  citrate  and  acetate  of  potash  should  be  given  iii  doses  of 
30-60  gr.  four  times  daily,  or  the  carbonate  or  citrate  of  mag- 
nesium or  lithium.  The  boro-citrate  of  magnesia  in  doses  of 
15  gr.  thrice  daily  is  well  borne. 

AlkaHne  mineral  waters,  such  as  Contrexeville  (Pavilion),  Vittel 
(Grande  Source),  and  Evian  (Cachet),  should  be  given,  and  a  visit 
to  one  of  these  spas  is  often  beneficial.  The  most  powerful  effect 
is  obtained  by  drinking  the  water  after  fasting.  For  this  reason 
a  large  draught  should  be  taken  in  the  early  morning,  and  another 
in  the  late  afternoon. 

Uric-acid  "  solvents  "  should  be  administered  by  the  mouth. 
Of  these  the  following  is  a  selection,  viz, :  piperazine,  4-15  gr.; 
sidonal,  7|  gr. ;  hexamethylenetetramine  (synonyms  urotropiue, 
formin,  cystamine,  cystogen,  metramine,  uritone),  5-15  gr. ;  hel- 
mitol,  15  gr. ;  hetralin,  7J-30  gr. ;  cystopurin,  30  gr. ;  chinotropine, 
up  to  90  gr, ;  uricedin,  15  gr. ;  uraseptin,  4  drachms.  Turpentine 
may  sometimes  be  administered  with  benefit  in  doses  of  10  minims 
in  capsule  thrice  daily  for  a  week  or  ten  days. 

Regular  graduated  exercise  in  the  open  air,  bathing  and 
Turkish  baths,  massage,  and  radiant  heat  baths  are  important 
adjuncts  to  treatment. 

Treatment  of  certain  synnptoms.  (a)  Renal  colic. — The 
pain  in  renal  colic  varies  greatly  in  severity.  In  severe  attacks 
the  patient  is  placed  in  a  hot  bath  and  a  hypodermic  injection  of 
morphine  sulphate  (j-|^  gr.)  with  atropine  sulphate  (y^o  gr-)  given.' 
On  his  return  to  bed  hot  fomentations  or  poultices  are  applied 
over  the  loin  and  abdomen.  The  pain  usually  subsides  half  an 
hour  after  the  injection.  Occasionally  it  is  necessary  to  repeat 
the  injection  after  some  hours.  Very  rarely  chloroform  has  to 
be  administered  and  the;  patient  kept  lightly  under  its  influence 
for  an  hour  or  more.  If  this  becomes  necessary  and  the  stone 
is  known  to  be  lying  at  the  upper  end  of  the  ureter,  a  ureteric 
catheter  may  be  passed  and  the  stone  pushed  back  into  the  renal 
pelvis.  The  injection  of  a  small  quantity  of  sterilized  oil  into 
the  ureter  has  facilitated  the  passage  of  a  descending  calculus 
(Schmidt). 

(6)  Renal  hematuria. — Hsematuria  is  seldom  severe  in  renal 
calculus,   but  there  may  be  profuse  haemorrhage  after  exertion 


XVII]  RENAL   CALCULUS:    OPERATION  269 

or  a  fall  or  blow.  The  patient  should  rest  in  bed  with  an  ice-bag 
over  the  kidney.  A  hypodermic  injection  of  morphia  should  be 
given  and  10  or  15  gr.  of  calcium  lactate  administered  by  mouth 
every  four  hours.  Ergotin  may  be  given  hypodermically,  but  is 
of  doubtful  value.  For  persistent  and  severe  hsematuria  operation 
is  necessary. 

(c)  The  treatment  of  calculous  anuria  is  discussed  later  (p.  282). 

Operative  treatment. — When  a  diagnosis  of  renal  calculus 
is  made  the  stone  should,  unless  in  some  exceptional  cases,  be 
removed  without  delay.  It  is  unwise  to  wait  in  expectation  of 
a  small  stone  passing  down  the  ureter,  for  it  is  impossible  to  judge 
from  the  size  and  shape  of  the  stone  whether  its  position  in  the 
pelvis  or  calyx  will  permit  of  its  descent.  Moreover,  there  are 
the  dangers  of  dilatation  of  the  kidney  and  haematogenous  in- 
fection while  it  remains  in  the  kidney,  and  the  same  dangers  and 
that  of  calculous  anuria  during  its  descent  along  the  ureter.  The 
danger  of  nephrolithotomy  in  experienced  hands  is  very  small. 

Cases  that  are  unsuitable  for  operation  are  {a)  those  of  extensive 
bilateral  calculous  disease,  either  aseptic  with  signs  of  progressive 
failure  of  the  renal  function,  or  when  there  is  widespread  sepsis 
and  ursemic  symptoms  are  present  or  are  easily  induced  by  expo- 
sure or  other  causes  ;  (b)  those  in  which  small  calculi  are  frequently 
passed  and  the  X-rays  do  not  show  a  large  single  shadow  or  a 
collection  of  small  shadows  in  the  kidney.  Operation  in  cases  of 
this  kind  is  followed  by  a  recurrence  of  the  stone  formation 
without  any  prolongation  of  the  interval.  They  are  suitable  for 
diuretic  and  spa  treatment. 

Before  commencing  the  operation  for  removal  of  a  stone  the 
following  information  should  be  in  possession  of  the  surgeon : — 

1.  The  position  and  number  of  calculi. — The  whole  urinary  tract 
must  be  examined  by  the  X-rays.  The  assistance  of  an  opaque 
bougie  in  the  ureter  is  sometimes  necessary  to  distinguish  doubtful 
shadows.     The  bladder  must  be  examined  with  the  cystoscope. 

2.  The  presence  of  a  second  kidney  and  its  functional  state. — 
This  is  ascertained  by  examination  of  the  ureteric  orifice  and 
the  observation  of  an  efEux,  by  chromocystoscopy,  and  by  the 
examination  of  the  urine  drawn  from  each  kidney  by  the  ureteral 
catheter  and  the  use  of  tests  for  the  renal  function.  This  in- 
formation is  absolutely  necessary  where  there  is  a  possibility  of 
nephrectomy  being  done. 

The  operations  which  may  be  performed  are — 

1.  Nephrolithotomy. 

2.  Pyelolithotomy. 

3.  Nephrectomy. 


270  THE   KIDNEY  [chap. 

1.  Nephrolithotomy. — In  nephrolithotomy  the  kidney  is  ex- 
posed by  a  lumbar  incision  and  separated  from  its  fatty  capsule 
as  far  as  the  hilum.  It  is  then  carefully  palpated  for  a  hard  nodule 
which  would  indicate  the  presence  of  a  stone.  The  pelvis  is  also 
examined  and  the  finger  pressed  into  the  sinus  of  the  kidney. 
The  further  procedure  will  depend  upon  whether  a  hard  nodule 
is  discovered  or  not.  If  a  nodule  is  felt  in  the  substance  of  the 
kidney,  it  should  either  be  exposed  by  an  incision  on  the  convex 
border  of  the  organ,  or,  if  it  is  near  the  anterior  or  posterior 
surface,  it  may  be  cut  upon  directly. 

Needling  the  kidney  for  a  nodule  felt  in  its  substance  is  an 
unnecessary  procedure,  for  the  reason  that  if  the  nodule  is  a  stone 
it  must  be  cut  upon  ;  and  if  it  is  not  a  stone,  and  also  if  no  nodule 
can  be  felt,  the  surgeon  cannot  rest  content  with  the  meagre  in- 
formation afforded  by  passing  a  needle  into  the  kidney  substance, 
but  will  proceed  to  explore  the  organ  by  a  free  incision. 

If  nothing  is  felt,  the  kidney  should  be  explored.     The  ureter 


Fig.  61. — Author's  stone  forceps. 

is  first  separated  from  the  vessels  at  the  hilum,  which  are  com- 
pressed with  the  finger  and  thumb.  An  incision  is  made  in  the 
convex  border  of  the  kidney,  4  mm.  behind  the  most  prominent  line. 
The  incision  is  placed  in  the  middle  of  the  organ  and  extends  for 
2  in.  or  more.  The  cut  surfaces  are  separated,  and  the  finger  in- 
troduced into  the  renal  pelvis,  and  with  this  and  a  metal  sound 
a  careful  search  is  made  for  the  calculus.  Instead  of  making  a 
single  large  incision  a  slightly  smaller  incision  may  be  made  into  each 
pole  of  the  kidney,  and  by  this  means  the  extremities  of  the  organ 
are  searched  and  the  portion  intervening  between  the  incisions  is 
easily  examined.  If  a  stone  is  felt  in  the  pelvis  or  one  of  the  calyces 
the  incision  should  be  extended  so  that  it  is  exposed.  By  means  of 
forceps  or  a  fine  scoop  and  the  forefinger  the  calculus  is  removed. 
In  some  cases  in  which  there  is  a  short  pedicle,  or  in  a  stout 
or  muscular  patient  with  a  narrow  loin,  the  kidney  can  only  be 
partly  brought  into  the  wound.  In  such  cases  I  use  long  fine 
forceps  with  an  angled  grasping  extremity  which  can  be  passed 
along  the  forefinger  and  seize  the  calculus  just  beyond  its  tip.  (Fig. 
61.)     Occasionally  the  end  of    a  calculus  can  be  felt,  the  remain- 


XVII]  NEPHROLITHOTOMY  271 

ing  portion  being  connected  with  it  by  a  narrow  neck  tightlv 
grasped  by  the  opening  from  the  cah-x  into  the  pelvis ;  and  in 
larger  stones  the  branches  of  the  calculous  mass  are  tightly  grasped 
in  the  calyces.  The  kidney  must  be  freely  incised  and  the  calculus 
gradually  freed  by  working  with  the  finger-tip,  with  forceps,  and 
with  elevators,  and  by  incising  the  constrictions  and  bands  which 
bind  it  down.  The  search  for  multiple  calcuH  should  be  carefully 
pursued.  The  large  calcidus  should  be  examined  for  facets.,  for 
each  of  which  a  calculus  must  be  found.  A  good  radiogram  is  of 
great  assistance,  and  should  be  before  the  surgeon  at  the  operation. 
In  isolated  scattered  calcuH  it  is  of  especial  value. 

A  number  of  small  stones  Iving  close  together  frequently  appear 
as  a  single  shadow.  Small  seed-Uke  calcuh  or  soft  phosphatic 
material  are  removed  by  a  copious  stream  of  warm  lotion  from 
an  irrigator  after  packing  the  perirenal  space  with  gauze. 

The  stones  ha\'ing  been  removed  from  the  kidnev,  the  ureter 
should  be  carefully  examined.  The  upper  portion  is  easily  pal- 
pated with  the  finger  as  far  as  the  brim  of  the  pehis.  A  long  fine 
gum-elastic  bougie  of  even  calibre  is  now  passed  down  the  ureter 
into  the  bladder.  Should  this  be  arrested  at  any  part  of  the 
ureter  the  finger  is  passed  along  the  outside  of  the  ureter,  and  at 
the  end  of  the  bougie  a  calculus  may  be  discovered.  A  complete 
radiographic  examination  of  the  urinary  tract,  together  with 
sounding  the  ureter  before  the  operation  is  decided  upon,  "^ill 
shorten  this  part  of  the  operation. 

After  removal  of  the  calculi  the  kidney  wound  should  be  closed 
with  sutures.  Soft  catgut  sutures  are  most  suitable.  Catgut  pre- 
served in  iodine  and  chromic  catgut  are  too  hard,  and  cut  out. 
The  sutures  are  introduced  with  round-bodied  straight  needles, 
and  are  passed  about  an  inch  from  the  edge  of  the  woimd.  Thev 
are  placed  about  half  an  inch  apart,  and  five  or  six  interrupted 
sutures  usually  sufiice.  They  are  tied  slowly,  and  not  too  tightlv, 
lest  they  cut  out  through  the  friable  kidney  substance.  When 
the  kidney  substance  has  not  been  destroyed  these  sutures  will 
suf6.ce,  but  occasionally  it  is  necessary  to  introduce  a  mattress 
suture  to  control  bleeding  from  a  large  vessel.  If  mattress  sutures 
are  used  a  second  row  of  interrupted  sutures  should  be  introduced 
near  the  edge  of  the  wound,  as  otherwise  the  hps  become  everted. 

When  the  kidney  substance  has  been  much  reduced  there  is 
more  difficulty  in  closing  the  womid  satisfactorily.  The  thin  lips 
become  everted  or  inverted,  and  there  is  some  danger  of  the  sutures 
tearing  out.  In  the  cases  in  which  severe  haemorrhage  persists 
after  nephrolithotomy  the  bleeding  usually  arises  from  a  suture 
havitig  penetrated  into  a  dilated  cah^x,  and  either  cut   out  and 


272  THE   KIDNEY  [chap. 

allowed  a  vessel  to  bleed,  or  torn  through  a  vessel  from  being 
tied  too  tight. 

When  there  is  sepsis  with  dilatation  of  the  kidney,  drainage  of 
the  intrarenalr  cavity  is  necessary,  and  this  is  provided  by  a  rubber 
tube  of  moderate  size,  which  is  retained  in  the  kidney  cavity  by 
a  catgut  stitch  passed  through  the  edges  of  the  kidney  incision. 
The  perirenal  space  should  also  be  drained. 

Bangers  of  ne'phrolithotomy. — The  dangers  of  nephrolithotomy 
are  haemorrhage  and  septic  infection. 

Cases  have  been  recorded  in  which,  at  the  end  of  the  operation 
of  nephrolithotomy,  very  severe  haemorrhage  occurred  from  a  large 
vessel  and  necessitated  nephrectomy.  These  cases  are,  however, 
very  rare,  and  there  is  usually  no  difl&culty  in  controlling  the 
haemorrhage  by  sutures  so  long  as  the  fibrous  capsule  is  intact. 
If  the  capsule  has  been  stripped  from  the  kidney  the  sutures  cut 
out  very  readily. 

Bleeding  may,  however,  commence  after  the  operation,  the 
blood  escaping  into  the  pelvis  and  causing  haematuria.  This 
postoperative  haematuria  may  assume  serious  proportions,  and 
clotting  may  occur  in  the  bladder,  or  it  may  persist  and  cause 
profound  anaemia  and  even  death. 

When  postoperative  haematuria  is  moderate,  treatment  by 
absolute  rest  and  the  application  of  an  ice-bag,  together  with 
small  doses  of  morphia  and  the  administration  of  calcium  lactate, 
10-15  gr.  every  four  hours  for  two  days,  may  be  tried.  Should 
this  fail  to  arrest  the  bleeding,  operation  should  not  be  too  long 
delayed ;  and  further,  if  the  haemorrhage  is  alarming  from  the 
first,  operation  should  be  performed  at  once. 

The  kidney  should  be  rapidly  exposed  and  the  previous  incision 
opened.  Usually  a  quantity  of  blood  escapes  under  tension.  A 
stream  of  hot  lotion  should  be  directed  into  the  cavity,  and  then 
a  medium-sized  rubber  tube  introduced  into  the  renal  pelvis. 
Round  the  tube  long  strips  of  aseptic  gauze  are  packed.  The 
patient  may  be  infused  on  the  table,  and  continuous  rectal  infusion 
commenced  on  returning  to  bed.  This  treatment  usually  sufl&ces 
to  control  the  haemorrhage,  and  after  three  days  the  packing  is 
removed,  or,  if  necessary,  renewed. 

Sepsis  may  arise  from  a  kidney  already  infected,  or  may  be 
introduced  at  the  operation.  Septic  pyelonephritis  sometimes 
follows  nephrolithotomy,  and  frequently  causes  severe  haematuria. 
Postoperative  haematuria  when  combined  with  elevation  of  the  tem- 
perature is  usually  due  to  this  cause.  Perirenal  suppuration  may 
occur.  The  infection  usually  subsides,  and  only  very  rarely  is  there 
an  infection  of  the  lumbar  wound  necessitating  opening  it  up. 


XVII]  PYELOLITHOTOMY  273 

Results. — The  results  are  influenced  by  the  presence  or  absence 
of  sepsis  previous  to  the  operation.  Some  authorities,  notably 
Morris,  regard  as  cases  of  nephrolithotomy  only  those  in  which 
the  kidney  is  healthy  and  there  is  no  infection.  Most  surgeons 
look  upon  all  cases  of  removal  of  calculi  from  the  kidney  as  cases 
of  neplirolithotomy. 

The  results  of  nephrolithotomy  in  cases  uncomplicated  by 
sepsis  or  dilatation  show  a  very  low  death-rate.  Watson  collected 
135  such  cases  with  3  deaths  (2-2  per  cent.) ;  Rovsing,  115  cases 
of  nephrolithotomy  in  non-infected  cases  with  7  deaths  (6-08  per 
cent.). 

In  infected  cases  the  mortality  is  high.  Schmieden  collected 
211  cases  with  43  deaths  (20-3  per  cent.),  and  the  statistics  of 
Kiister  show  251  cases  with  50  deaths  (19-9  per  cent.). 

The  causes  of  death  are  septicaemia  or  toxsemia,  anuria  and 
uraemia,  and  haemorrhage. 

A  patient  under  my  care  died  of  gangrene  of  both  lower 
extremities  after  the  removal  of  several  large  stones  from  the  left 
kidney.  At  the  operation  a  large,  hard,  inflammatory  mass  was 
found  around  the  aorta,  and  thrombosis  had  probably  spread 
from  this. 

After  nephrolithotomy  the  wound  usually  heals  rapidly,  even 
where  mild  infection  has  been  present.  In  infected  cases  a 
fistula  may  persist,  and  this  is  occasionally  due  to  calculi  having 
been  left  in  the  kidney,  or  to  ureteral  or  pelvic  obstruction.  In 
Schmieden's  cases  (infected)  a  fistula  followed  the  operation  in 
22*2  per  cent.  In  Watson's  collection  (infected  and  non-infected) 
there  were  fistulae  in  8'0  per  cent. 

2.  Pyelolithotomy. — By  this  term  is  understood  the  removal 
of  a  calculus  through  an  incision  in  the  pelvis  of  the  kidney. 

The  kidney  is  drawn  out  of  the  lumbar  wound.  The  organ  is 
grasped  in  the  left  hand  of  the  operator  and  turned  forwards  and 
upwards  so  that  the  posterior  aspect  of  the  pelvis  is  exposed.  The 
fat  covering  the  pelvis  is  removed  with  dissecting  forceps.  A 
posterior  branch  of  the  renal  artery  lying  immediately  within  the 
renal  sinus  and  irregular  vessels  must  be  avoided.  If  a  stone  is 
felt  in  the  pelvis  it  is  made  prominent  by  pressure  of  the  fingers 
on  the  front  of  the  pelvis,  and  a  longitudinal  incision  is  made  upon 
it  through  the  posterior  wall.  The  stone  is  then  removed  with 
forceps. 

If  a  stone  is  not  felt,  the  kidney  is  given  to  an  assistant  to  hold, 

and  a  longitudinal  incision  is  made  in  the  pelvis  about  |  in.  in 

length,  a  fine  catgut  suture  passed  through  each  lip,  and  the  wound 

held  open  by  these  sutures.     A  probe  is  now  introduced,  and  the 

s 


274 


THE   KIDNEY 


[chap. 


pelvis  and  calyces  are  explored.  (Fig.  62.)  If  a  calculus  is  now 
felt,  the  probe  is  held  in  position  and  a  pair  of  forceps  slipped 
along  it,  the  stone  grasped  and  removed. 

After  removal  of  the  stone  the  edges  of  the  wound  in  the  pelvis 
are  brought  together  by  interrupted  stitches  of  fine  catgut.  Over 
this  a  row  of  Lembert's  sutures  may  be  inserted. 

Since  1905  I  have  covered  all  wounds  in  the  renal  pelvis  mth 
a  flap  of  the  fibrous  capsule  turned  down  from  the  kidney  and 
stitched  in  place.  This  has  proved  very  successful  in  preventing 
the  escape  of  urine  and  promoting  primary  healing.  Mayo  re- 
commends a  flap  of  fatty  tissue  for  the  same  purpose. 


Fig.  62. — Pyelolithotomy. 

The  left  kidney  is  delivered  from  the  lumbar  wound  and  turned  forwards.     The  pelvis  has  been 

opened,  and  the  edges  of  the  wound  are  held  apart  by  catgut  sutures.     The  calyces  are  being 

sounded  with  a  fine  probe. 

A  drainage  tube  is  placed  behind  the  kidney  and  the  lumbar 
wound  closed.  Usually  there  is  no  escape  of  urine,  but  occasion- 
ally some  urine  leaks  for  a  few  days.  Rarely  this  continues  for  a 
fortnight  or  longer,  and  a  urinary  fistula  may  become  established. 

The  cases  which  are  suitable  for  pyelolithotomy  are  those  of 
small  unbranched  stones  lying  in  the  pelvis. 

As  a  method  of  exploration  of  the  kidney  for  stone,  pyelotomy 
is  usually  considered  inferior  to  nephrotomy.  The  relative  merits 
of  these  operations  ■will  be  discussed  later. 

Results. — In  Schmieden's  statistics  there  are  54  cases  of  pyelo- 
lithotomy, of  which  36  (66*7  per  cent.)  were  completely  healed. 
There  were  12  (22-2  per  cent.)  recoveries  with  fistula,  and  6  (11*1 


XVII]         NEPHRO-  AND  PYELOLITHOTOMY        275 

per   cent.)    died.     These    operations    were    performed    on    uncom- 
plicated cases  only. 

In  my  experience  tlie  percentage  of  fistula  following  nephro- 
lithotomy and  pyelolithotomy  given  in  the  statistics  quoted  is 
much  too  high. 

Nephrolithotomy  and  pydoUthotoimj  compared. — By  nephro- 
lithotomy all  calculi  which  are  not  so  extensive  or  so  fixed  as  to 
require  nephrectomy  can  be  removed.  Pyelolithotomy  can  only 
be  performed  for  small  or  moderate-sized  calculi  occupying  the 
renal  pelvis  or  calyces,  and  it  is  only  in  regard  to  these  cases  that 
the  relative  merits  of  the  two  operations  can  be  discussed.  In 
cases  where  there  is  a  short  pedicle  and  a  deep  loin,  pyelolithotomy 
may  be  impossible,  while  nephrolithotomy  presents  no  insuperable 
difficulty.  In  nephrolithotomy  the  incision  through  the  renal 
tissue  produces  some  destruction  of  the  tissue,  and  the  sutures 
introduced  to  control  haemorrhage  cause  further  damage.  Each 
suture  is  a  sclerotic  centre,  and  fibrosis  may  extend  for  some  dis- 
tance around  it.  In  pyelolithotomy  there  is  no  destruction  of 
renal  tissue  by  incision,  tearing,  or  suture. 

In  nephrolithotomy  there  is  some  immediate  and  remote  danger 
of  haemorrhage.  In  pyelolithotomy  a  retropelvic  vessel  may  be 
wounded,  but  there  is  little  probability  of  severe  haemorrhage. 
In  an  exploration  of  the  kidney  for  stone  which  cannot  be  felt 
in  the  pelvis,  pyelotomy,  as  already  mentioned,  is  looked  upon  as 
inferior  to  nephrotomy.  In  a  single  large  pelvis  (ampullary  pelvis) 
Legueu  looks  upon  the  two  operations  as  being  equally  efficient. 

When  there  is  a  branched  pelvis,  nephrolithotomy  is  the  belter 
operation,  as  it  is  difficult  to  explore  all  the  calyces  satisfactorily 
with  an  instrument,  and  the  small  calibre  makes  the  introduction 
of  the  finger  impossible.  The  exploration  in  nephrolithotomy  is 
also  difficult  in  many  cases.  After  incising  the  kidney  the  finger 
may  pass  through  the  wound  into  the  sinus  of  the  kidney  without 
entering  the  pelvis  at  all,  and  a  probe  appears  at  the  hilum  along- 
side the  pelvis.  The  sounding  of  each  calyx  by  an  instrument,, 
when  the  pelvis  is  much  branched,  is  less  likely  to  be  successful 
through  a  nephrotomy  than  through  a  pyelotomy  wound.  In 
cases  where  a  small  radiographic  shadow  is  present  and  the  stone 
is  not  felt  in  the  renal  pelvis,  and  the  kidney  can  be  brought  out 
of  the  wound,  I  usually  explore  the  kidney  first  by  pyelotomy 
and  sounding  with  a  probe,  and,  if  this  fails,  open  the  kidney 
and  explore  the  calyces  through  both  incisions  simultaneously. 

Urinary  fistula  is  stated  to  occur  more  frequently  after  pyelo- 
lithotomy than  after  nephrolithotomy,  and  the  statistics  of  a. 
number  of  cases  support  this  ^dew. 


276  THE   KIDNEY  [chap. 

The  danger  of  a  fistula  following  pyelolithotomy  has  been  over- 
stated. The  probability  of  postoperative  fistula  is  slight  if  care 
be  taken  to  remove  any  obstruction  to  the  flow  of  urine  along 
the  ureter  and  there  be  accurate  suturing  of  the  pyelotomy  wound. 
In  cases  of  moderate-sized  unbranched  calculi  in  the  renal  pelvis, 
and  for  many  small  concealed  stones  in  the  calyces,  pyelolithotomy 
is  preferable  to  nephrolithotomy,  for  it  is  more  easily  performed, 
there  is  no  danger  of  haemorrhage,  and  the  kidney  is  not  damaged. 

3,  Nephrectomy. — Primary  nephrectomy  is  rarely  practised 
for  calculus.  Under  the  following  conditions  it  may  become 
necessary : — 

1.  Severe  uncontrollable  haemorrhage  during  nephrolithotomy. 

2.  Where  the  kidney  is  atrophied  or  destroyed  by  suppura- 

tion or  dilatation. 

3.  Where  calculi  are  so  numerous  and  large  that  they  cannot 

be  removed  without  destroying  the  kidney. 

4.  A  malignant  growth  has  been  found  with  renal  calculi  and 

necessitated  nephrectomy. 
Secondary  nephrectomy  may  be  called  for  in — 

1.  Urinary  fistula  causing  great  discomfort  irremediable  by 

other  means. 

2.  Recurrence  of  stone  with  an  atrophied  kidney. 

3.  Prolonged  renal  suppuration. 

The  operation  may  be  very  difficult  on  account  of  extensive 
adhesions  to  the  peritoneum,  colon,  liver,  aorta,  and  vena  cava. 
An  intracapsular  operation  is  often  impossible  from  the  adhesion 
of  the  kidney  to  the  capsule,  or  a  portion  of  the  kidney  may  be 
shelled  out  while  the  rest  of  the  organ  is  firmly  adherent. 

Watson  collected  the  following  statistics  : — 

Primary  nephrectomy,  136  cases,  41  deaths  (SO'l  per  cent.). 
Secondary         „  33      „         6        „        (18-1  „       ). 

Bilateral  calculi.- — It  is  unwise  to  remove  the  stones  from 
"both  kidneys  at  the  same  operation.  The  better  kidney  should 
first  be  operated  on,  in  case  it  may  become  necessary  to  perform 
nephrectomy  on  the  second  kidney  later.  Pyelolithotomy  should 
be  performed  on  both  sides  whenever  possible.  Where  a  small 
stone  is  present  in  one  kidney  and  a  large  stone  in  the  other,  the 
small  stone  should  be  removed  without  delay,  as  the  conditions 
favourable  for  calculous  anuria  are  present. 

Krister  collected  20  double  operations  and  found  10  successful 
cases,  3  recoveries  with  fistula,  and  7  deaths,  due  in  most  cases 
to  uraemia. 

Calculus  in  a  solitary   kidney. — A  conservative  operation 


XVII]  RENAL  CALCULUS  277 

is  here  a  necessity.  Pyelolithotomy  is  preferable  to  nephro- 
lithotomy whenever  possible.  Both  operations  have  been  suc- 
cessfully practised. 

The  same  limitation  applies  to  calculus  in  a  horseshoe  kidney. 

LITERATURE 

Albarran,  Traite  de  Chlrurgie  (Le  Dentu  et  Delbet). 

Badin,  These  de  Lyon,  1908. 

Bevan  ami  Smith,  S'iir(j.,  Oyn.,  and  Obst.,  1908,  p.  G75. 

Brodel,   .lohn.^   Hopkins  Hasp.  Bull.,  1901,  p.   10. 

Drew,   Trans.   Path.  Soc,  1897,  p.  130. 

Faltin,   Folia  Urol.,  1908,  H.  3,  4. 

Fenwick,  Ureteric  Meatuscopy  in.  Obscure  Diseases  of  the  Kidney.     1903- 

Freplin,  Arch.  /.  hlin.  Chir.,  1904,  p.  868. 

Gage  and  Seal,  Ann.  Surg.,  1908,  p.  378. 

Israel, -he/;.  /.  klin.  Chir.,  1900. 

Kummel,  Zeits.  f.  Urol.,  1908,  p.  193. 

Kuster,  Berl.  klin.  Woch.,  1894,  p.  35. 

Legueu,  Traite  Chirurgical  d'Urologie,  1910  ;  XF'  Sess.  de  I'Assoc.  Frang.  d'Urol., 

1908,  p.  561. 
Mayo,  Surg.,  Gyn.,  and  Obst.,  April,  1910. 
Moore,  Brit.  Med.   Journ.,  1911,  p.  737. 
Morris,  Surgical  Diseases  of  the  Kidney  and   Ureter.     1901. 
Newman,  Lancet,  1909,  p.  8. 
Robinson,  Neiv  York  Med.  Journ.,  1904,  p.  1113. 
Schade,  Miinch.  med.  Woch.,  1909,  No.  1. 
Shield,  Lancet,  1904,  p.  1074.- 
Stewart,  Amer.  Journ.  Med.  Sci.,  Aug.,  1905. 
Preindlsberger,   Wien.  klin.  Rundschau,  1900,  No.  46. 
Watson,  Diseases  and  Surgery  of  the  Genito-Urinary  System,  vol.  ii.     1909. 


CHAPTER  XVIII 
CALCULOUS  ANURIA 

Etiology. — Calculous  anuria  may  occur  at  any  age.  It  is  rare 
in  children,  although  cases  have  been  described.  It  is  most  frequent 
between  the  ages  of  40  and  60.  Men  are  more  often  affected  than 
women. 

The  calculus  which  causes  the  anuria  is  usually  small  and 
single.  The  immediate  cause  is  not  infrequently  violent  exercise, 
shaking  or  jarring  such  as  is  produced  by  riding  in  an  omnibus 
or  jumping ;  but  anuria  may  supervene  without  any  apparent 
exciting  cause. 

Pathology. — Suppression  of  urine  may  be  caused  not  only 
by  impaction  of  a  calculus,  but  also  by  the  gradual  destruction  of 
the  renal  tissue  from  the  action  of  calculi  until  it  is  insufficient 
to  carry  on  the  renal  function.  This  is  the  last  phase  of  long- 
standing bilateral  renal  calculi. 

By  calculous  anuria  is  understood  sudden  suppression  of  urine 
from  obstruction  caused  by  the  impaction  of  a  calculus  at  the 
outlet  of  the  renal  pelvis,  in  the  ureter,  or  very  rarely  in  the  bladder. 

On  the  obstructed  side  there  is  the  arrest  in  the  pelvis  or  ureter 
of  a  calculus,  usually  of  small  size,  with  complete  obliteration  of 
the  lumen  of  the  duct.  There  is  usually  only  one  calculus,  which 
is  most  frequently  arrested  at  the  upper  part  of  the  ureter.  Rarely, 
several  calculi  are  present.  Donnadieu  gives  the  situation  of  the 
calculus  in  61  cases  as  follows :  in  the  upper  part  in  34  cases,  in 
the  lower  part  in  16  cases,  and  in  the  middle  in  6  cases. 

The  obstructed  kidney  is  large  and  deeply  congested,  with 
ecchymoses  on  the  surface  and  in  the  substance,  and  the  pelvis 
contains  2  or  3  drachms  of  blood-stained  urine  under  considerable 
tension. 

The  condition  of  the  second  kidney  varies.  It  is  generally 
agreed  that  the  second  kidney  is  always  the  seat  of  some  organic 
change.  A  few  cases  have  been  recorded  in  which  the  second 
kidney  was  apparently  healthy,  but  Legueu,  and  most  authorities 
with  him,  holds  that  some  lesion  of  the  second  kidney  is  invari- 

278 


CHAP.  XVIII]  CALCULOUS  ANURIA  279 

able,  and  that  if  the  kidneys  which  were  supposed  to  be  intact 
had  been  examined  histologically  some  lesion  such  as  nephritis 
would  have  been  found.  In  most  cases  atrophy  or  sclerosis  is 
present. 

In  a  few  cases  (12  in  43  cases — Donnadieu)  this  ureter  is  also 
blocked  by  a  calculus,  and  more  rarely  the  second  kidney  is  want- 
ing (6  in  43  cases — Donnadieu). 

The  effect  of  the  impaction  of  the  calculus  on  the  kidney  of 
the  same  side  is  sudden  and  complete  obstruction  and  suppression 
of  its  function,  and  the  effect  on  the  opposite  kidney  is  reflex 
suppression.  Reflex  anuria  may  be  observed  when  the  second 
kidney  is  normal,  but  it  is  of  temporary  duration,  and  the  secretion 
is  re-established  when  the  first  effect  of  the  impaction  has  passed 
off.  When,  however,  the  second  kidney  is  diseased  the  secretion 
remains  suppressed  and  anuria  results. 

The  pathological  conditions  under  which  calculous  anuria  super- 
venes may  be  summed  up  as  follows  : — 

L  The  ureter  of  a  single  functional  kidney  is  blocked  by  stone. 
The  second  kidney  is  absent,  atrophied,  or  completely  destroyed 
by  disease. 

2.  The  ureters  of  two  functional  kidneys  are  simultaneously 
blocked  by  calculi. 

3.  The  ureter  of  one  functional  kidney  is  blocked  by  stone, 
and  the  function  of  the  second  kidney  is  suppressed  by  reflex 
influences  (uretero-renal  reflex).  The  second  kidney  is  always 
diseased,  and  this  renders  it  more  susceptible  to  reflex  influences 
and  less  able  to  re-establish  the  secretion  when  this  has  once  been 
suppressed. 

Symptoms. — The  kidney  on  the  recently  affected  side  is 
frequently  enlarged  and  tender,  and  there  is  rigidity  of  the  ab- 
dominal muscles,  especially  marked  on  this  side.  There  may  be 
tenderness  along  the  line  of  the  ureter  and  of  the  lower  end  of 
the  ureter  per  rectum.  The  calculus  is  occasionally  detected 
by  the  finger  in  the  rectum  or  vagina.  On  cystoscopic  examina- 
tion the  ureteric  orifice  on  the  recently  diseased  side  may  be  con- 
gested or  even  ecchymosed.  Rarely,  a  calculus  has  been  found 
projecting  from  the  orifice. 

Morris  describes  two  clinical  types  of  calculous  anuria,  namely, 
the  gouty,  fat,  and  apparently  robust  adult  past  middle  age  ;  and 
the  thin,  nervous,  dyspeptic  individual. 

Anuria  may  commence  without  pain  or  other  symptoms,  or 
there  may  be  indefinite  aching,  so  slight  as  to  be  forgotten  by  the 
patient,  who  is  unable  to  indicate  one  side  as  having  been  recently 
affected.     More  often  there  is   a   definite   and  sometimes  severe 


280  THE   KIDNEY  [chap- 

attack  of  renal  colic  accompanied  by  strangury,  and  the  urine  is 
diminished  in  quantity  or  at  once  suppressed.  As  the  attack 
passes  off,  the  secretion,  which  may  have  continued  in  small  quan- 
tity, ceases  altogether  and  anuria  becomes  established.  There  is 
a  period  of  tolerance  during  which  no  symptoms  are  present,  and 
a  period  of  intoxication. 

1.  Period  of  tolerance. — This  period  lasts  a  varying  time, 
the  average  duration  being  five  or  six  days.  It  may  be  as  short 
as  twenty-four  hours  or  may  be  prolonged  to  ten  or  even  to 
sixteen  days.  During  this  time  the  urine  may  be  absolutely  sup- 
pressed, not  a  drop  being  passed.  Frequently,  however,  some  urine 
is  secreted.  There  may  be  a  few  drachms  or  ounces  of  urine  con- 
taining blood,  or  the  anuria  may  be  interrupted  by  one  or  more 
intervals  of  copious  polyuria.  Many  pints  of  pale,  limpid  urine, 
of  1006  or  1008  specific  gravity,  and  with  very  small  quantities 
of  urea  and  urinary  salts  and  colouring  matter,  are  secreted.  The 
polyuria  ceases  as  suddenly  as  it  commenced,  and  anuria  is  again 
complete.  Several  intermissions  of  polyuria  may  be  observed,  and 
life  may  be  prolonged  in  these  cases  ;  in  a  case  recorded  by  Weber 
the  patient  lived  for  thirty  days. 

During  the  tolerant  stage  the  patient  may  feel  in  his  usual 
health,  and  is  able  to  conduct  his  business  and  get  about  in  appar- 
ently good  health.  After  some  days  digestive  disturbances  usually 
appear.  The  appetite  fails,  and  there  are  nausea,  constipation, 
and  flatulence.  The  patient  becomes  sleepless  and  irritable,  and 
suffers  from  headache  and  lassitude. 

2.  Period  of  intoxication. — The  signs  of  intoxication  set  in 
usually  about  the  fifth  to  the  seventh  day.  The  patient  becomes 
heavy  and  drowsy,  at  first  at  intervals,  and  later  continuously. 
He  can  be  roused,  but  quickly  relapses  again.  There  is  often 
restlessness,  and  later  there  are  hallucinations  and  muttering 
delirium.  The  pupils  are  contracted,  and  there  is  usually  twitch- 
ing of  muscles.  Convulsions  do  not  occur.  The  patient  may 
complain  of  inability  to  move  one  or  both  legs,  and  the  knee-jerks 
are  slow  or  abolished.  The  pulse  is  slow  (40  or  50  per  minute) ; 
the  respiration  is  slow  and  increasingly  irregular,  and  may  assume 
the  Cheyne-Stokes  type.  The  temperature  is  subnormal  (97°-98° 
F.).  (Edema  of  the  feet  and  ankles  may  be  observed,  but  is 
frequently  absent.  Hiccough  is  an  occasional  symptom,  but  is 
more  likely  to  occur  in  cases  where  pyelonephritis  is  the  cause  of 
anuria  than  in  calculous  anuria.  Vo22iiting  appears  at  first  after 
food,  and  later  becomes  frequent  and  exhausting.  The  bowels  are 
constipated.  Attacks  of  dyspnoea  occur,  and  the  patient  usually 
dies  suddenly  in  one  of  these ;    or  there  may  be  increasing  coma 


XVIII]      CALCULOUS  ANURIA:    DIAGNOSIS         281 

and  gradual  heart  failure.  Urasmic  symptoms  may  set  in  at  any 
time.  Death  sometimes  takes  place  suddenly  without  any  symp- 
toms of  uraemia  having  appeared. 

Diagnosis. — There  are  two  important  points  in  diagnosis : 
(1)  What  is  the  cause  of  the  anuria  ?     (2)  Which  side  is  affected  ? 

1.  The  cause  of  the  anuria. — In  calculous  anuria  there  may 
have  been  previous  attacks  of  renal  colic,  or  the  passage  of  calculi 
or  gravel,  or  calculi  may  have  been  removed  from  the  kidney  or 
bladder  by  operation.  One  kidney  may  be  enlarged  and  tender, 
and  a  calculus  may  be  detected  by  the  finger  at  the  lower  end  of 
the  ureter.     Cystoscopic  examination  may  assist  in  the  diagnosis. 

The  absence  of  fever  excludes  such  forms  of  anuria  as  that 
caused  by  acute  pyelonephritis.  From  other  forms  of  obstructive 
anuria  calculous  anuria  is  diagnosed  by  exclusion.  The  bladder  is 
examined  for  evidence  of  new  growth,  and  for  this  diagnosis  the 
cystoscope  may  be  necessary.  I  have  seen  a  case  of  obstructive 
anuria  due  to  malignant  growth  of  the  bladder  where  the  patient 
had  suffered  from  slight  symptoms  of  cystitis  for  five  months  and 
suddenly  developed  anuria.  There  was  no  enlargement  of  the  kid- 
neys. Other  forms  of  obstruction,  such  as  cancer  of  the  uterus  or 
prostate,  and  other  pelvic  tumours,  must  be  excluded.  Hydrone- 
phrosis may  develop  in  these  forms  of  obstruction,  but  may  be  absent. 

Postoperative  and  traumatic  anuria  are  excluded  by  the  his- 
tory. Toxic  anuria  due  to  such  drugs  as  cantharides,  mercury, 
lead,  etc.,  is  gradual  in  its  onset,  and  is  accompanied  by  other 
characteristic  symptoms. 

Anuria  occurring  in  the  course  of  acute  or  chronic  nephritis 
is  preceded  by  symptoms  which  leave  little  doubt  as  to  the  cause 
of  the  suppression  of  urine.  The  oedema  and  cardio- vascular 
symptoms,  and  the  prominent  place  which  headache,  convulsions, 
and  coma  take  in  the  symptomatology,  usually  suffice  for  a  diag- 
nosis. Anuria  is  the  last  phase  of  such  conditions  as  tuberculosis 
and  polycystic  disease,  but  the  previous  history  provides  sufficient 
evidence  on  which  to  base  a  diagnosis. 

2.  The  side  affected. — The  patient  sometimes  gives  a  his- 
tory covering  many  years  of  pain  and  attacks  of  renal  colic  on 
one  side,  with  a  recent  attack  of  colic  on  the  other  side.  The 
side  of  the  recent  pain  is  that  of  the  active  kidney  and  recently 
blocked  ureter.  The  abdominal  muscles  are  rigid  on  the  affected 
side.  The  kidney  is  tender  and  may  be  enlarged,  and  there  is 
tenderness  along  the  line  of  the  ureter  and  at  the  lower  end  of 
the  ureter,  felt  from  the  rectum  or  the  vagina.  Radiography,  if 
it  is  available,  may  give  important  information.  Extensive  shadows 
in  one  kidney  will  point  to  the  organ  having  been  inactive  or  feebly 


282  THE   KIDNEY  [chap. 

functional,  and  a  shadow  in  the  Hne  of  the  opposite  ureter  will 
indicate  and  localize  the  cause  of  the  anuria. 

Cystoscopy  may  show  an  open  congested  or  oedematous  or 
ecchymosed  ureter  on  the  diseased  side,  and  an  efflux  of  bloody 
urine  may  be  observed  if  some  urine  is  still  being  secreted. 

Catheterization  of  the  ureter  has  demonstrated  the  affected 
side  and  the  position  of  the  stone,  and  Krebs  has  by  this  means 
displaced  a  calculus  and  obtained  relief  from  the  anuria.  The 
position  of  the  calculus  will  frequently  be  discovered  in  making 
the  diagnosis ;  should  it  not  be  found  at  the  operation,  time 
should  not  be  spent  in  looking  for  it. 

Prognosis. — If  the  anuria  is  untreated  by  operation,  death 
occurs  in  71  per  cent,  of  cases  according  to  Legueu,  and  in  67  per 
cent,  according  to  Donnadieu.  It  takes  place  usually  about  the 
tenth  or  twelfth  day,  after  two  or  three  days  of  the  intoxication 
stage.  In  cases  which  recovered,  the  date  of  the  spontaneous 
relief  was  the  third  day  in  1,  the  fifth  to  the  tenth  in  10,  the 
thirteenth  in  1,  the  fourteenth  in  1,  the  fifteenth  in  1,  and  later 
than  the  fifteenth  in  2. 

Treatment. — Operation  should  be  performed  at  the  earliest 
possible  moment  in  all  cases  of  calculous  anuria.  It  has  been 
held  that  operation  may  be  delayed  until  the  fifth  or  sixth  day, 
as  ursemic  symptoms  rarely  supervene  before  that  time.  This 
delay  could  only  be  justified  by  a  large  proportion  of  spontaneous 
recoveries,  and  such  does  not  exist.  Death,  if  it  takes  place,  is  a 
result  not  of  the  operation  but  of  the  condition  for  which  the 
operation  is  performed. 

Huck's  statistics  show  that  the  mortality  rises  each  day  that 
operation  is  delayed.  Before  the  fourth  day  there  is  a  mortality 
of  25  per  cent.,  before  the  fifth  day  of  30-7  per  cent.,  and  before 
the  sixth  day  of  42"  1  per  cent.  Operations  should  therefore  be 
performed  as  soon  as  anuria  is  established  and  the  diagnosis  clearly 
made.  The  presence  of  uraemic  symptoms  does  not  contra-indicate 
operation.  Successful  cases  of  operation  under  these  conditions 
have  been  recorded. 

In  addition  to  operation,  other  measures  should  be  employed  to 
re-establish  the  secretion  of  urine.  Diuretics  such  as  Contrexe- 
ville  or  Evian  water,  tea,  theocin  sodium  acetate  in  doses  of  4  gr. 
combined  with  digitalis,  every  four  hours,  should  be  administered. 
Infusion  of  normal  saline  solution  into  a  vein  acts  as  a  powerful 
diuretic  ;  two  pints  should  be  given  during  or  after  the  operation,  or  a 
solution  of  2J  or  5  per  cent,  of  glucose  may  be  used  {see  under  Anuria, 
p.  19).  A  purge  should  be  administered,  and  every  means  taken 
by  hot  packs  and  vapour  baths  to  obtain  a  free  action  of  the  skin. 


XVIII]    CALCULOUS  ANURIA:    TREATMENT        283 

Nature  of  the  operation. — This  will  to  some  extent  depend 
upon  the  position  of  the  obstructing  stone,  the  possibility  of  accu- 
rately localizing  it,  and  the  ease  or  difficulty  with  which  it  can  be 
removed.  The  operation  for  calculous  anuria  is  one  of  emergency 
performed  under  the  worst  possible  conditions,  and  it  should  be 
realized  that  it  is  more  important  to  relieve  the  obstruction  and 
do  it  quickly  than  to  carry  out  an  operation  for  the  removal  of 
calculus  of  the  ureter.  Nephrotomy  should  be  performed  where 
the  stone  is  localized  to  the  pelvis,  where  no  accurate  localization 
of  the  stone  has  been  possible,  or  where  the  stone  has  been  local- 
ized to  the  ureter  but  its  position  is  such  as  to  necessitate  a  pro- 
longed operation  which  the  patient  is  considered  unfit  to  undergo. 

If  the  stone  is  found  it  should  be  removed  ;  if  it  is  not  found 
a  large  drainage  tube  should  be  placed  in  the  pelvis  and  the  wound 
in  the  kidney  lightly  packed  with  gauze.  After  the  anuria  has 
been  relieved  an  operation  for  the  removal  of  the  obstructing 
calculus  will  be  undertaken. 

Pyelotomy  may  be  substituted  for  nephrotomy  where  the 
stone  is  easily  reached  and  removed  through  a  pelvic  wound. 

Ureterotomy  should  be  performed  where  the  obstructing  cal- 
culus has  been  accurately  locahzed  and  is  easily  accessible,  as  in 
the  lateral  vaginal  fornix  or  in  the  middle  or  upper  segments  of 
the  ureter. 

The  nature  of  the  operation  in  46  cases  collected  by  Morris 
was — nephrotomy  34,  pyelotomy  5,  ureterotomy  7. 

Watson  suggests  that  where  a  diagnosis  of  the  side  affected 
has  not  been  made  previously  to  operation,  and  the  kidney  on 
exposure  does  not  appear  to  be  adequate  to  carry  on  the  renal 
function,  the  second  kidney  should  at  once  be  exposed  and  incised. 

Results. — Watson  collected  205  cases  of  calculous  anuria,  and 
found  the  following  results  of  treatment : — 

Treated  without  operation,  110;  deaths,  80;  mortaUty,  72  •?  per  cent. 
Treated  by  operation,  95;       ,,        44;  ,,  46  "3         ,, 

Huck  has  shown  that  the  mortality  of  cases  operated  upon 
before  the  fourth  day  is  25  per  cent. 

The  results  are  capable  of  great  improvement  if  the  necessity 
jor  early  and  rapid  operation  is  fully  reahzed. 

LITERATURE 
Donnadieu,  These  de  Bordeaux,  1895. 
Huck,  These  de  Nancy,  1904. 
Krebs,  Petersb.  med.  Woch.,  1903,  No.  52. 
Legueu,   Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1895,  p.  865. 
Morris,  Surgical  Diseases  of  the  Kidney  and  Ureter,  ii.  145.     1901. 
Watson    and    Cunningham,    Diseases    and    Surgery    of    the   Genito- 
urinary System,  ii.  193.     1909, 


CHAPTER  XIX 
OPERATIONS  ON  THE  KIDNEY 

The  indications  for  operation  upon  the  kidney  are  discussed 
under  each  disease  for  which  it  may  be  required.  Only  the  tech- 
nique need  be  considered  here. 

Preparation. — Careful  preparation  of  the  bowel  is  important, 
for  a  distended  colon  interferes  greatly  with  the  ease  with  which 
a  kidney  operation  is  performed,  and  there  is  a  tendency  to  dis- 
tension of  the  colon  following  the  operation,  which  is  increased, 
when  the  bowel  is  already  filled  with  flatus.  A  mild  aperient 
should  be  given  on  two  successive  nights,  and  then  the  patient 
allowed  to  sleep  without  further  purgation  on  the  night  previous 
to  the  operation,  but  an  enema  is  given  three  hours  before  the 
patient  enters  the  theatre.  Violent  purgation  should  be  avoided. 
The  diet  should  be  light  for  two  days  before  operation,  and  the 
patient  should  have  an  abundant  supply  of  fluids  up  to  two  hours 
before  it  is  done.  The  latter  direction  is  especially  important 
where  there  is  a  possibility  of  suppression  of  urine  taking  place 
from  advanced  renal  disease.  I  prefer  chloroform,  given  by  an 
experienced  ansesthetist,  to  other  forms  of  anaesthesia. 

The  preparation  of  the  skin  will  vary  with  the  individual 
surgeon.  An  efficient  method  is  to  wash  the  skin  of  the  field  of 
operation,  the  evening  before  operation,  with  soap-and-water  and 
ether  soap,  and,  after  drying  it  thoroughly,  to  paint  it  with  a  solu- 
tion of  iodine  in  rectified  spirit  (2  per  cent.),  and  apply  a  dry  aseptic 
dressing.  At  the  time  of  the  operation  the  field  is  again  painted 
with  the  iodine  solution.  The  field  should  extend  to  the  middle 
line  anteriorly  and  beyond  the  spines  of  the  vertebrae  posteriorly, 
as  high  as  the  level  of  the  nipple  and  as  low  as  the  pubes. 

The  methods  of  approach  are  lumbar  or  extraperitoneal,  and. 
abdominal   or  transperitoneal.     The  lumbar  route  is  that  com- 
monly used,   transperitoneal   operations   being  reserved  for  large 
growths  or  cases  where  it  is  important  first  to  explore  the  abdo- 
minal cavity. 

Lumbar  operations. — In  addition  to  the  instruments  required! 

28-i 


CHAP.  XIX]        THE   "  KIDNEY   POSITION  " 


285 


for  any  major  operation,  bone  forceps,  necrosis  forceps,  and 
a  periosteum  elevator  slioukl  be  piovided  in  case  resection  of 
a  rib  may  be  required.  Two  pairs  of  pedicle  clamps  and  a  pedicle 
needle  are  necessary  where  nephrectomy  is  proposed,  and  round - 
bodied  needles,  straight  and  curved,  are  used  for  stitcliing  the 
kidney  in  nephrotomy  or  nephropexy.  The  patient  is  placed  on 
the  sound  side  (Fig.  63)  with  a  firm  pillow  under  the  loin — a  round 
sausage-Hke  air  cushion  of  large  size  is  most  convenient  for  this 
purpose — or  there  may  be  a  special  elevating  apparatus  attached  to 
the  table.  The  lower  knee  is  drawn  well  up  and  the  upper  one 
fully  extended,  and  the  legs  are  steadied  by  a  sand  pillow.     The 


Fig.  63. — The  "kidney  position." 

Note  the  air-cushion  under  the  loin,  the  lower  leg  flexed  and  the  upper  leg  extended. 

lower  shoulder  and  the  pelvis  should  rest  on  the  table.  Too  great 
elevation  of  the  loin  by  the  pillow  permits  the  patient  to  roll  back- 
wards or  forwards.  In  this  position  the  distance  between  the  iliac 
crest  and  the  costal  margin  is  increased  to  its  utmost.  There  is 
a  tendency  for  the  uppermost  arm  to  fall  across  the  chest  and 
impede  the  breathing,  and  in  order  to  obviate  this  Carter  Braine's 
arm-rest  is  used,  and  the  arm  placed  horizontally  upon  it.  (Figs. 
64,  65.)  In  stout,  heavy  subjects  the  upper  shoulder  tends  to  roll 
upwards  and  interfere  with  the  breathing,  and  it  may  be  necessary 
to  have  the  shoulder  controlled  by  a  nurse. 

The  prone  position  is  sometimes  used,  the  patient  being  placed 
upon  his  face  with  a  pillow  beneath  the  upper  part  of  the  abdomen, 
but  the  lateral  decubitus  is  that  almost  universally  adopted. 


286 


THE  KIDNEY 


[chap. 


The  incision  is  oblique,  extending  from  the  angle  between 
the  12th  rib  and  the  erector  spinae  mass  of  muscle  downwards  and 
forwards  towards  the  anterior  superior  iliac  spine  for  a  distance 
varying  according  to  the  build  of  the 
patient  and  the  magnitude  of  the  operation 
upon  the  kidney.  (Fig.  66,  a  a'.)  The 
upper  end  of  the  incision  may  be  with 
advantage  made  to  curve  vertically  up- 
wards so  as  to  cross  the  12th  rib,  and  a 
somewhat  curved  incision  passing  almost 
vertically  from  the  12th  rib  along  the 
outer  border  of  the  erector  spinse  muscle 
and  curving  forwards  an  inch  above  the 
crest  of  the  ilium  is  sometimes  preferable 
to  the  strictly  oblique  incision.  (Fig.  66, 
bb'.)  When  the  ilio-costal  space  is  narrow 
the  incision  will  be  more  transverse,  as 
little  is  to  be  gained  by  obliquity  in  such 
a  case. 

A    vertical    incision    along    the    outer 


Fig.    64. —  Garter 

Braine's  arm-rest  for 

kidney  operations. 


Fig.  65. — Showing  arm-rest  in  use,  to  allow  expansion  of  thorax. 


XIX] 


INCISIONS   FOR   EXPOSURE 


287 


border  of  the  erector  spinsc  muscle  from  the  12th  rib  to  the  ihac 
crest  is  sometimes  used  for  simple  procedures  such  as  nephropexy. 
(Fig.  66,  D  d'.)  For  this  incision  the  patient  lies  prone  with  a 
pillow  beneath  the  abdomen.  The  modern  incisions  are  the  out- 
come of  the  following  incisions,  which  possess  an  historical  interest, 


Fig.  66. — Incisions  for  exposure  of  kidney. 

A  A',  Usual  oblique  incision.     B  B',  Curved  incision  with  long  vertical  limb  carried 
over  12th  rib.     D  D',  Vertical  incision. 

viz.  :  vertical  incision  along  the  outer  edge  of  the  erector  spinse 
mass  of  muscles,  used  by  Simon  and  Czerny  ;  horizontal  incisions, 
used  by  Pean  and  Kiister  ;  and  oblique  incisions,  used  by  von 
Bergmann  and  Guyon. 

Before  the  incision  is  commenced  the  skin  should  be  scratched 


288 


THE   KIDNEY 


[chap. 


with  a  needle  so  that  there  is  a  series  of  scratches  crossing  the 
line  of  the  proposed  incision  transversely  and  about  an  inch  apart. 
These  serve  to  show  the  proper  relation  of  the  upper  and  lower 
lips  when  the  wound  comes  to  be  closed. 

The  skin,   subcutaneous  fascia  and  fat  are  incised,   and  the 


Fig.  67. — Side  view  of  incisions  for  exposure  of  kidney. 

A  A',  Oblique  incision.     B  B',  Curved  incision.     C  C,  Gregoire's  incision. 

latissimus  dorsi  and  posterior  part  of  the  external  oblique  exposed. 
The  latissimus  dorsi  is  cut  through,  and  some  fibres  of  the  serratus 
posticus  superior,  the  12th  rib,  the  edge  of  the  erector  spinee  muscle, 
the  transversalis  or  lumbar  fascia,  the  external  oblique,  and  below 
this  the  internal   oblique,  are   exposed.     The   incision  is   carried 


xix] 


EXPOSURE   OF   KIDNEY 


289 


through  the  external  ()bU(|uc  muscles  and  some  fibres  of  the  internal 
oblique,  and  then  the  lumbar  fascia  is  incised  in  the  line  of  the 
skin  wound,  and  the  fascia  of  Zuckerkandl  comes  into  view.  In 
making  this  incision  the  12th  dorsal  vessels  and  nerve  are  encoun- 
tered. If  possible,  they  should  be  turned  aside,  but  they  usually 
intersect  the  line  of  the  incision  and  must  be  cut  across.  The  first 
and  second  fingers  of  the  left  hand  are  inserted  beneath  the  muscles 
of  the  abdominal  wall  and  the  peritoneum  pushed  backwards. 
With  scissors  the  remaining  muscles  (internal  oblicjue  and  trans- 
versalis)  are  severed,  cutting  between  the  fore  and  middle  finger 


Fig.  68. — Exposure  of  kidney. 

Cutting  through  the  posterior  layer  of  perirenal  fascia  (Zuckerkandl's  fascia). 

of  the  left  hand  to  the  full  extent  of  the  wound.  At  the  upper 
angle  of  the  wound  the  lower  border  of  the  12th  rib  is  freely  ex- 
posed by  cutting  some  fibres  of  the  serratus  posticus  inferior  and 
the  external  arcuate  ligament.  Before  cutting  the  latter  the 
finger  should  be  slipped  up  internally  to  it,  so  as  to  protect  the 
pleura,  which  sometimes  descends  to  this  level.  Bleeding  may 
follow  from  cutting  the  last  intercostal  vessels,  which  should  be 
tied.  The  fascia  of  Zuckerkandl  is  picked  up  in  forceps  and  in- 
cised (Fig.  68),  and  the  lemon-yellow  fat  of  the  fatty  renal  capsule 
exposed.  The  edges  of  the  fascia  are  seized  and  the  kidney  ex- 
posed by  stripping  with  the  forefinger.     A  stronger  band  of  fibres 


290 


THE   KIDNEY 


[chap. 


containing  the  perirenal  fat  is  frequently  found  at  the  lower  pole  of 
the  kidney,  and  by  traction  on  this  the  organ  is  brought  into  view 
and  may  be  raised  into  the  wound.  Where  there  are  adhesions 
and  increase  in  the  fat  around  the  kidney  there  may  be  consider- 
able difficulty  in  freeing  the  kidney.  This  is  done  partly  by  blunt 
dissection  with  the  fingers  and  partly  by  cutting  with  scissors. 
Where  a  strong  band  of  adhesions  is  met  with,  this  is  clamped 
and  cut,  and  a  ligature  placed  upon  it.  The  hand  is  inserted 
beneath  the  ribs,  and  the  upper  pole  of  the  kidney  isolated  and 
finally  brought  down  into  the  wound.     (Fig.  69.) 

The  peritoneum  may  be  wounded  when  the  perineal  fascia 


.->*^'' 


Fig.  69.^ — Delivery  of  the  kidney  from  the  lumbar  wound. 

is  opened,  or  during  the  isolation  of  the  kidney.  The  extremities 
of  the  peritoneal  wound  are  immediately  picked  up  in  forceps  and 
the  rent  closed  by  means  of  a  continuous  catgut  suture.  Occasion- 
ally a  rent  very  high  up  under  the  liver  in  a  prolonged  and  difficult 
nephrectomy  must  be  left  unsutured.  I  have  never  had  after- 
trouble  from  wounds  of  the  peritoneum  even  in  septic' diseases  of 
the  kidney. 

Nephrotomy  and  nephrostomy. — When  exploration  of  the 
kidney  is  the  object  of  the  operation  the  kidney  is  incised  along 
its  convex  border.  The  surgeon  grasps  the  vascular  pedicle  of 
the  kidney  between  the  thumb  and  forefinger  of  the  left  hand, 
and  incises  the  kidney  in  the  exsanguine  line  of  Hyrtl,  parallel  to 
and  a  little  behind  the  curved  border.  (Fig.  70.)  The  knife  is 
entered  vertically  to  the  surface,  and  the  size  of  the  incision  varies. 


xix] 


NEPHROTOMY 


291 


The  object  of  the  nephrotomy  is  to  examine  the  kidney  substance 
and  also  to  explore  the  calyces.  It  is  necessary,  therefore,  to  open 
the  calyces,  and  for  this  purpose  I  prefer  two  incisions,  one  at  the 
lower  pole  and  the  other  at  the  upper  pole,  to  a  single  larger  incision 
in  the  middle  of  the  kidney.  This  double  incision  is  suited  for 
the  exploration  of  the  bifid  form  of  renal  pelvis.  Keeping  up 
pressure  on  the  renal  pedicle,  the  lips  of  the  wound  are  parted 
and  the  kidney  tissue  is  examined.     The  forefinger  is  inserted  and 


Fig.  70. — Nephrotomy. 

The  left  hand  is  grasping  the  pedicle. 

carefully  explores  the  calyces,  care  being  taken  not  to  rupture 
the  attachment  of  the  pelvis  to  the  kidney  by  rough  manipulation. 

In  short,  thick-set  individuals,  in  whom  the  renal  pedicle  is 
short  and  inelastic,  it  may  be  difficult  or  impossible  to  bring  the 
kidney  into  the  wound  or  to  deliver  it  on  the  loin.  In  such  cases 
full  use  must  be  made  of  the  additional  space  given  by  detaching 
the  muscles  and  arcuate  ligament  from  the  lower  border  of  the  r2th 
rib.  It  may  further  be  necessary  to  excise  a  portion  of  this  rib, 
or  to  cut  it  with  bone  forceps  and  mobilize  it.  The  kidney  must 
be  incised  in  situ,  and  the  operation  becomes  much  more  difficult. 

The  nephrotomy  wound  is  closed  by  means  of  thick  catgut 


292 


THE  KIDNEY 


[chap. 


sutures  (No.  3  or  4)  on  round-bodied  needles.  One  or  even  two 
mattress  sutures  may  be  required  where  the  bleeding  is  profuse ; 
they  are  placed  1  or  IJ  in.  from  the  edge  of  the  incision,  and 
tied  carefully  so  as  not  to  cut  the  kidney  capsule  and  tissue.  The 
wound  is  closed  with  interrupted  catgut  sutures,  three  or  four 
in  number.     (Fig.  71.) 

The  kidney  is  returned  to  its  fatty  bed  and  a  drainage  tube 
placed  in  the  upper  extremity  of  the  lumbar  wound.  Before 
commencing  to   suture  the  muscles,  the  skin  and    subcutaneous 


Fig.  71. — Methods  of  suturing  nephrotomy  wound. 

A,  Mattress  sutures.      B,  Superficial  sutures  to  bring  edges  of  wound  together  over 
mattress  suture.      C,  Interrupted  sutures  deeply  placed. 

fat  should  be  freed  for  an  inch  or  so  from  the  cut  edge  of  the 
muscles.  The  muscular  wound  is  closed  by  means  of  a  single  or 
a  double  row  of  interrupted  sutures  of  thick  catgut.  The  sutures 
are  all  introduced,  and  clipped  with  artery  forceps.  The  air  is  now 
allowed  to  escape  from  the  cushion  under  the  loin,  and  the  edges 
of  the  wound  fall  together.  The  sutures  are  then  tied.  The  skin 
wound  is  closed  with  interrupted  silkworm-gut  sutures,  care  being 
taken  that  the  upper  lip,  which  slides  forwards  as  much  as  an 
inch  or  more  on  the  lower  one,  is  brought  into  its  proper  position. 
The  scratches  made  before  commencing  the  incision  indicate  the 
proper  relations  of  the  two  lips. 


xix] 


LUMBAR  NEPHRECTOMY 


293 


In  nephrostomy  the  Iddiioy  is  drained  temporarily  or  per- 
manently. This  is  p(!rl'()rnied  usually  for  hydronephrosis  or  i)yo- 
ncplirosis.  The  kidney  is  exposed,  but  is  not  raised  from  its  bed. 
The  most  prominent  part  is  incised  with  a  knife,  and  a  large 
drainage  tube  inserted,  a  stitch  being  introduced  through  the 
kidney  tissue  and  the  tube.  A  second  tube  may  be  placed  along- 
side this  to  drain  the  perinephritic  tissue. 

When  permanent  drainage  is  desired,  an  apparatus  for  collect- 
ing the  urine  is  applied  {see  p.  159). 

Lumbar     nephrectomy. — When    nephrectomy    is     proposed 


Fig.  72. — Lumbar  nephrectomy. 

Ligature  of  ureter  previous  to  section. 

the  preliminary  steps  are  the  same  as  those  already  described. 
The  incision  may  be  prolonged  as  far  as  the  anterior  iliac  spine, 
and  it  may  occasionally  be  necessary  to  excise  the  12th  rib  in 
order  to  gain  access  to  the  upper  part  of  the  kidney  and  to  the 
renal  pedicle.  In  doing  so  care  must  be  taken  to  avoid  damaging 
the  pleura.  Wounds  of  the  pleura  have  frequently  been  recorded, 
but  they  do  not  appear  to  have  been  followed  by  collapse  of  the 
lung  or  other  untoward  results. 

In  operating  for  malignant  growths  of  the  kidney  which  are 
adherent  at  the  upper  pole  it  is  wise  to  open  the  peritoneum  out- 
side the  colon,  and  introduce  the  hand  in  order  to  palpate  the 
upper  pole  of  the  kidney  and  ascertain  whether  the  growth  has 


294 


THE   KIDNEY 


[chap. 


spread  to  the  peritoneum  and  surrounding  structures,  and  is 
therefore  inoperable. 

Modifications  of  the  operation  in  malignant  growths  are 
described  elsewhere  (pp.  200-2). 

In  lumbar  nephrectomy  for  stone,  tubercle,  growth,  or  other 
disease,  the  separation  of  adhesions  may  be  a  long  and  tedious 
process.  The  adhesions  are  clamped  and  tied  as  the  operation 
proceeds.  The  ureter  is  cut  across  between  two  ligatures  (Fig.  72), 
and  the  lower  pole  of  the  kidney  moves  more  freely.  The  kidney 
is  freed  on  its  posterior  and  convex  surfaces  and  the  upper  pole 


Fig.  73. — Lumbar  nephrectomy. 

The  ureter  has  been  ligatured  and  cut,  the  vascular  pedicle  clamped,  and  ligatures  are 
.  being  placed  on  each  vessel  separately. 

reached.  The  pedicle  is  now  reduced  by  dissection  to  its  vascular 
elements,  the  pelvis  being  freed  from  its  posterior  surface.  A 
clamp  is  placed  on  the  pedicle  close  to  the  kidney  but  avoiding 
the  pelvis.  The  kidney  is  cut  away,  leaving  the  pedicle  in  the 
grasp  of  the  clamp. 

Attention  is  now  turned  to  the  ligature  of  the  pedicle  (Fig.  73). 
If  the  vessels  are  readily  separated  by  dissection  a  strong  catgut 
suture  is  placed  upon  each  and  the  clamp  carefully  removed. 
In  some  cases  it  is  impossible,  from  the  short,  thick,  rigid  con- 
dition of  the  pedicle  resulting  from  chronic  inflammation,  to  do 
this,  and  the  pedicle  must  be  transfixed  with  a  double  silk  thread 


XIX]  NEPHRECTOMY  295 

(No.  4  or  5)  and  tied  in  two  portions,  cure  being  taken  to  draw 
the  knots  tight  and  to  plaee  the  hgatures  as  far  behind  the  clamp 
as  possible.  The  clamp  is  now  cautiously  removed,  the  stump 
being  held  with  a  jniir  of  Kocher's  forceps  until  it  is  evident  that 
all  is  secure.  Difhculty  in  dealing  with  the  pedicle  may  arise 
from  the  unexpected  discovery  of  tuberculous  or  malignant  glands 
adherent  to  it  and  to  the  aorta  or  vena  cava.  Careful  dissection 
is  required  in  such  cases. 

The  treatment  of  the  perirenal  fat  and  lymphatic  area  and 
of  the  ureter  is  described  under  the  different  diseases  for  which 
nephrectomy  is  required. 

A  large  rubber  tube  is  placed  in  the  upper  angle  of  the  wound 
and  leads  to  the  neighbourhood  of  the  stump  of  the  pedicle,  and 
another  leads  downwards  into  the  iliac  fossa.  These  tubes  are 
removed  on  the  fourth  day. 

The  wound  is  closed  in  the  same  manner  as  in  nephrotomy. 

Subcapsular  nephrectomy. — Where  there  is  excessive  peri- 
nephritis with  the  formation  of  dense  adhesions  and  a  large  mass 
of  fibro-fatty  tissue  the  kidney  may  be  removed  by  subcapsular 
nephrectomy. 

The  incision  is  carried  down  to  the  perirenal  fat,  which  is 
freely  incised  in  a  vertical  direction,  grasped  with  sponge  forceps 
and  held  aside.  The  forefinger  is  now  introduced  between  the 
kidney  and  the  capsule,  and  swept  first  round  the  lower  pole  and 
then  round  the  upper.  A  broad  pedicle  is  isolated,  consisting 
of  the  renal  pelvis,  vessels  and  a  mass  of  fibro-fatty  tissue.  This 
is  clamped  and  the  kidney  removed. 

The  broad  pedicle  may  now  be  tied  in  sections  with  stout 
silk  and  the  clamp  cautiously  removed.  Great  care  is  taken  to 
get  a  good  grasp  with  the  ligatures.  If  the  pedicle  is  not  too 
broad  it  should  be  transfixed  and  tied  in  two  portions.  Another 
method  which  may  be  successful  is  to  make  an  incision  in  the 
capsule  round  the  pedicle  and  isolate  it  beyond  the  fibro-fatty 
mass. 

Nephrectomy  by  morcellement. — This  is  seldom  rec|uired, 
but  it  may  be  necessary  in  removing  a  kidney  the  seat  of  long- 
standing suppurative  pyelonephritis.  The  organ  is  removed  in 
portions,  large  clamps  being  used  to  control  the  bleeding.  These 
should  be  placed  as  near  the  pedicle  as  possible,  and  will  usually 
have  to  be  left  in  situ.  They  are  removed  in  forty-eight  hours, 
the  wound  being  rapidly  and  firmly  packed  if  bleeding  should 
follow  their  removal. 

Partial  nephrectomy  has  been  advocated  in  the  treatment  of 
tuberculosis  and  new  growths  of  the  kidney,   but  has  now  been 


296  THE   KIDNEY  [chap. 

abandoned  as  it  is  impossible  to  define  the  limits  of  these  diseases 
and  remove  the  whole  disease  by  this  method. 

Ligature  of  the  renal  vessels. — In  a  few  cases,  where  ne- 
phrectomy has  been  judged  too  formidable  an  undertaking  owing 
to  previous  unsuccessful  operations  and  to  extensive  adhesions, 
transperitoneal  ligature  of  the  renal  artery  and  vein  has  been 
practised  as  a  substitute  for  nephrectomy.  According  to  Kellock, 
who  has  recorded  a  case  and  has  made  observations  on  the  cadaver, 
the  operation  on  the  right  side  is  more  difficult  than  that  on  the 
left,  owing  to  the  position  of  the  duodenum  and  pancreas.  Aberrant 
arteries  may  give  rise  to  difficulties. 

Difficulties  in  lumbar  operations. — The  chief  difficulties 
encountered  in  lumbar  operations  on  the  kidney  are — (1)  great 
adipose  development ;  (2)  narrow  ilio-costal  space,  which  is  found 
in  short,  thick-set  individuals ;  (3)  high  position  of  the  kidney  and 
short  vascular  pedicle ;  (4)  adhesions  and  excessive  development 
of  the  perinephritic  fat ;  (5)  distension  of  the  colon  due  to  over- 
purgation  or  to  want  of  preparation ;  (6)  deformities  of  the  spine 
or  hip-joint. 

Abdominal  nephrectomy. — The  patient  lies  on  his  back. 
A  vertical  incision  is  made  either  in  the  semilunar  line  on  the 
affected  side  or  through  the  rectus  sheath  parallel  to  the  median 
line.  In  the  latter  case  the  rectus  muscle  is  displaced  towards 
the  median  line,  and  the  posterior  layer  of  the  sheath  and  the  peri- 
toneum are  incised.  The  colon  is  exposed  and  the  small  intestine 
packed  off.  An  incision  is  made  through  the  outer  layer  of  the 
mesocolon,  and  the  bowel  displaced  inwards.  The  kidney  is  ex- 
posed by  incising  the  anterior  layer  of  perinephritic  fascia. 

The  procedure  is  now  similar  to  that  adopted  in  the  lumbar 
operation.  After  removal  of  the  kidney  a  stab  wound  is  made  in 
the  loin  and  a  large  rubber  drain  passed  through  it.  The  wound 
in  the  mesocolon  and  the  abdominal  wound  are  then  closed. 

Dangers  of  nephrectomy. — Wounds  of  the  pleura  and  peri- 
toneum have  been  referred  to.  They  are  treated  by  immediate 
suture,  and  do  not  give  rise  to  further  trouble. 

Shock. — Shock  is  the  most  frequently  fatal  complication.  It 
occurs  in  a  pronounced  degree  in  kidney  operations  compared 
with  operations  on  other  organs.  Traction  on  the  renal  pedicle 
during  removal  of  the  kidney  has  an  immediate  and  powerful 
effect  on  the  pulse  and  respiration.  In  prolonged  operations  the 
shock  may  be  profound.  It  may  commence  towards  the  end 
of  the  operation  or  after  the  patient  is  returned  to  bed,  and  it  is 
frequently  observed  three  or  four  hours  after  nephrectomy.    Saline 


XIX]  DANGERS   OF  NEPHRECTOMY  297 

subcutaneous  infusion  may  bo  administered  durin<^  the  operation 
if  the  pulse  begins  to  fail.  Rectal  saline  infusion  (enteroclysis) 
should  be  commenced  when  the  patient  is  returned  to  bed,  and 
continued  for  several  hours,  and  repeated  if  necessary.  Brandy 
or  strong  coffee  may  be  added  to  the  rectal  infusion.  Hypodermic 
injections  of  strychnine  (irV^aV  gr.)  and  intramuscular  injection  of 
camphor  (|-3  gr.),  or  of  camphor  (J  gr.)  with  ether  (17  min.), 
may  be  required. 

Haemorrhage. — During  the  operation  haemorrhage  may  be 
due  to  a  number  of  causes.  An  aberrant  artery  may  be  torn 
during  separation  of  perirenal  adhesions.  These  arteries  enter 
the  upper  or  lower  pole  of  the  kidney,  and  may  give  rise  to  severe 
haemorrhage.  Care  should  be  taken  to  clamp  all  suspicious  bands 
before  cutting  them  across.  Long  artery  forceps  are  useful  for 
seizing  the  artery  when  it  has  been  inadvertently  torn.  The  in- 
ferior vena  cava  has  been  torn  during  the  removal  of  a  malignant 
growth.  The  tear  is  usually  lateral,  and  is  followed  by  very  serious 
venous  bleeding.  When  the  wound  is  small  and  can  be  picked 
up  with  a  pair  of  forceps  a  lateral  ligature  should  be  placed  on 
it,  and  this  has  resulted  in  recovery  in  several  cases.  When  the 
wound  is  more  extensive  lateral  suture  has  been  practised,  and 
where  a  severe  transverse  tear  has  been  produced  double  circular 
ligature  of  the  vena  cava  below  the  renal  veins  is  recommended. 

Haemorrhage  from  the  pedicle  during  the  operation  is  frequently 
due  to  carelessness  or  flurry  in  tying  the  ligature,  resulting  in 
the  ligature,  from  being  too  loosely  applied,  shpping  after  removal 
of  the  clamp.  A  renal  vein  may  be  injured  in  passing  the  ligature 
through  the  pedicle.  Good  exposure,  careful  dissection,  and  care 
in  tying  the  ligature  prevent  such  accidents. 

Should  bleeding  occur,  the  pedicle  is  at  once  seized  with  pres- 
sure forceps  and  the  individual  bleeding-point,  if  possible,  secured, 
or  a  new  ligature  placed  more  firmly  around  the  whole  pedicle. 
Finally,  in  a  difficult  case  where  the  condition  of  the  patient  does 
not  permit  of  much  time  being  spent  in  again  securing  the  pedicle, 
a  clamp  should  be  applied,  and  left  in  position  for  three  days, 
when  it  is  cautiously  removed. 

Haemorrhage  after  the  operation  may  be  due  to  oozing  from 
unligatured  vessels  or  to  slipping  of  the  pedicle  ligature.  If  it  is 
severe  the  wound  must  be  opened  up,  the  clots  removed,  and 
the  bleeding-point  secured,  or,  this  failing,  the  cavity  is  firmly 
packed  with  strips  of  gauze,  which  are  removed  in  two  days. 

Anuria. — Anuria  may  occur  immediately  after  nephrectomy, 
or  there  may  be  gradual  failure  of  the  renal  function.  This  is 
due  to  inadequacy  of  the  second  kidney.     Before  nephrectomy 


298  THE   KIDNEY  [chap,  xix 

the  state  of  the  second  kidney  should  be  examined  by  catheter- 
ization of  the  ureters  and  the  use  of  the  tests  for  the  renal  func- 
tion. The  value  of  these  methods  in  discriminating  cases  which 
are  inoperable  is  strikingly  demonstrated  by  the  statistics  of 
nephrectomy  for  tuberculosis  of  the  kidney  previous  to  their  use, 
and  recent  statistics  since  these  methods  have  been  employed. 

Anuria  and  oliguria  are  treated  according  to  the  directions 
given  at  p.  19. 

Remote  dangers  are  sepsis  and  pulmonary  embolism. 
Sepsis  is  avoided  by  care  in  preventing  the  soiling  of  the  wound 
with  pus  or  tuberculous  material  when  cutting  the  ureter  and 
removing  the  kidney,  and  in  general  aseptic  technique.  Should 
the  muscular  layers  of  the  wound  be  infected,  this  may  necessitate 
the  opening  up  of  the  wound  and  entail  a  prolonged  and  tedious 
convalescence.  Peritonitis  is  a  danger  in  transperitoneal  oper- 
ations for  septic  diseases  of  the  kidney. 

The  operations  of  nephrolithotomy,  pyelotomy,  pyelolithotomy, 
nephropexy,  and  decapsulation  are  described  in  other  chapters. 


PART  IL—THE  URETER 


CHAPTER  XX 

SURGICAL  ANATOMY-PHYSIOLOGY 
EXAMINATION 

Surgical  anatomy. — The  ureter  extends  from  the  pelvis  of  the 
kidney  to  the  bladder.  The  upper  end  commences  at  the  lower 
pole  of  the  kidney  at  the  level  of  the  2nd  lumbar  vertebra,  and 
there  is  a  slight  narrowing  as  it  joins  the  renal  pelvis.  From 
this  point  the  ureter  passes  vertically  downwards  to  cross  the  iliac 
vessels  at  the  brim  of  the  bony  pelvis,  descends  into  the  pelvis, 
and  turns  forwards  and  then  inwards  to  pierce  the  wall  of  the 
bladder.     (Fig.  74.) 

The  ureter  has  several  curves  (Fig.  75).  The  first  or  lumbar 
part  is  vertical,  inclining .  slightly  inwards  at  the  upper  part.  It 
forms  a  slight,  very  long  curve  with  a  postero-external  concavity. 
There  is  a  second,  more  pronounced  curve,  with  the  concavity 
postero-external,  as  the  ureter  crosses  the  iliac  vessels  and  drops 
into  the  pelvis ;  a  third,  wider  but  well-marked  curve,  with  the 
concavity  forwards ;  and  finally  the  duct  curves  inwards  towards 
the  middle  line  to  pierce  the  wall  of  the  bladder.  At  the  upper 
end  the  ureters  are  about  10  cm.  apart,  at  the  level  of  the  iliac 
crests  7  cm.,  at  the  level  of  the  brim  of  the  pelvis  5  cm.,  at  the 
widest  part  of  the  pelvic  curve  they  lie  10  cm.  apart,  and  at 
the  point  of  entry  into  the  bladder  wall  4  cm. 

The  ureter  is  30  cm.  (12  in.)  long,  and  has  a  varying  calibre. 
Gelatin  casts  show  that  there  are  certain  narrow  points  in  the 
normal  ureter.  According  to  Poirier  there  are  two  types.  In 
the  first  there  are  two  contractions — the  first  at  the  junction  of 
the  ureter  and  pelvis,  the  second  at  the  point  of  entrance  into  the 
bladder.  In  the  second  type  there  is,  in  addition  to  these  narrow 
points,  a  third  contraction  at  the  brim  of  the  pelvis.  Between 
these  points  there  are  two  "  dilatations  " — the  lumbar  dilatation, 
which  is  the  larger,  and  the  pelvic  dilatation. 

299 


300 


THE   URETER 


[chap. 


The  relations  to  the  skeleton  as  seen  in  radiography  are  very 
important,  and  are  fully  described  in  the  section  dealing  with 
examination  of  the  ureter. 

Relations  of  the  ureter. — The  lumbar  portion  of  the  ureter 
lies  upon  the  sheath  of  the  psoas  muscle  and  crosses  the  genito- 
crural  nerve.  Anteriorly  it  lies  in  close  relation  with  the  peri- 
toneum, and  is  crossed  by  the  spermatic  or  ovarian  vessels  at  the 
level  of  the  3rd  lumbar  vertebra.     On  the  left  it  is  crossed  by  the 


Fig.  74. — Diagram  of  renal  pelvis  and  ureter,  showing  relation 
to  spine,  pelvic  girdle,  and  great  vessels.  Drawn  from 
radiograms. 

left  colic  and  sigmoid  branches  of  the  inferior  mesenteric  artery, 
and  on  the  right  by  the  right  colic  and  ilio-colic  branches  of  the 
superior  mesenteric  artery.  If  the  vermiform  appendix  passes 
upwards  and  inwards  it  crosses  in  front  of  the  lower  part  of  this 
segment  of  the  ureter. 

At  the  brim  of  the  pelvis  the  duct  crosses  the  common  ihac 
vessels  near  their  bifurcation,  or  the  external  iliac  vessels,  and 
is  covered  by  peritoneum.  The  ureters  are  intimately  related 
to  the  peritoneum,  and  when  this  membrane  is  raised  the  duct 
remains  attached  to  it. 


XX] 


RELATIONS  OF   URETER 


301 


Iiitcnially  the  ri<,'ht  ureter  is  in  contact  with  tiie  inferior  vena 
cava ;  the  left  ureter  is  in  relation  to,  but  not  in  contact  with,  the 
aorta. 

The  relations  of  the  pelvic  portion  vary  in  male  and  female. 

In  the  male  the  ureter  crosses  the  brim  of  the  pelvis  and  passes 
downwards,  backwards,  and  a  little  outwards,  lying  in  front  of 
the  spine  of  the  ischium  and  crossing  in  front  of  the  internal  iliac 
vessels.  External  to  it  is  the  parietal  layer  of  the  pelvic  fascia 
covering  the  obturator  inter- 
nus,  and  it  crosses  internally 
to  the  obliterated  hypogastric 
artery  and  the  obturator  vessels 
and  nerve.  Internally  it  lies 
in  relation  to  the  peritoneum. 
The  duct  now  turns  forwards 
and  inwards  on  the  upper  sur- 
face of  the  levator  ani  and 
beneath  the  peritoneum,  and  is 
crossed  by  the  vas  deferens 
before  it  enters  the  muscular 
wall  of  the  bladder. 

In  the  female  the  relations 
of  the  first  part  of  the  pelvic 
portion  are  the  same  as  in  the 
male,  except  that  the  ovarian 
vessels  and  the  ovary  lie  in 
relation  to  it.  The  second  part 
turns  inwards  on  the  upper 
surface  of  the  levator  ani  and 
crosses  beneath  the  broad  liga- 
ment and  alongside,  and  then 
in  front  of,  the  lateral  fornix 
of  the  vagina  and  the  cervix 
uteri,  and  enters  the  wall  of 
the  bladder.  In  this  part  of 
its  course  it  is  surrounded  by 

a  dense  plexus  of  veins  belonging  to  the  uterine  and  vaginal 
plexuses,  and  it  crosses  below  and  behind  the  uterine  artery. 
The  ureter  opens  into  the  bladder  at  the  level  of  the  upper  one- 
third  with  the  lower  two-thirds  of  the  vagina,  and  it  is  adherent 
to  the  vaginal  wall  at  the  lateral  fornix. 

The  ureters  pass  very  obliquely  through  the  muscular  wall 
of  the  bladder,  lying  beneath  the  mucous  membrane  for  some  part 
of  this  intramural  course,  which  extends  altogether  for  |  in.     The 


Fig.  75. — Diagrams  showing  curves 
and  dilatations  of  ureter. 

a,  Lateral  curves  ;  i',  antero-posterior  curves. 


302  THE   URETER  [chap. 

ureteric  orifices  open  from  J  to  1  in.  apart  as  fine  slit-like  orifices 
on  a  low  muscular  ridge. 

Blood-vessels.— The  sources  of  the  arterial  supply  are  numer- 
ous. From  above  downwards  the  ureter  receives  branches  from 
the  renal  artery,  the  spermatic  or  ovarian,  the  aorta,  the  common 
iliac,  the  hypogastric,  the  uterine  in  the  female  and  the  vesical 
in  the  male.  The  arterioles  anastomose  along  the  whole  length 
of  the  duct.  The  veins  empty  into  the  renal,  spermatic  or  ovarian, 
and  hypogastric  veins. 

The  blood  supply  of  a  small  area  of  vesical  mucous  membrane 
surrounding  the  orifice  of  the  ureter  is  intimately  connected  with 
the  ureteric  vessels.  The  area  is  inflamed  in  ureteral  inflamma- 
tions, and  congested  when  obstruction  to  the  ureteric  vascular 
drain  is  present. 

The  nerves  are  derived  from  the  renal,  spermatic  or  ovarian, 
and  hypogastric  and  vesical  plexuses. 

Physiology. — The  urine  descends  from  the  renal  pelvis  to 
the  bladder,  propelled  by  waves  of  vermicular  contraction  which 
pass  down  the  ureter.  The  exposed  ureter  can  be  stimulated  to 
contract  by  touching  it  with  a  pair  of  forceps  or  other  instrument. 
Two  forms  of  contraction  are  observed — a  contraction  of  the 
circular  muscle  fibres,  and  a  writhing  movement  due  to  contraction 
of  the  longitudinal  muscle.  The  natural  waves  of  contraction  are 
initiated  by  contractions  which  commence  in  the  renal  pelvis  and 
sweep  the  whole  length  of  the  duct,  and  are  further  stimulated 
by  the  passage  of  the  urine  along  the  duct.  If  the  ureter  is  blocked 
or  fistulous  at  its  upper  end,  so  that  no  urine  travels  along  it,  only 
a  feeble  contraction  reaches  the  bladder.  If  the  fistula  is  low 
down  near  the  bladder  the  contraction  at  the  vesical  orifice  is 
as  powerful  as  if  urine  were  discharged.  These  facts  show  that 
the  passage  of  the  urine  along  the  tube  is  not  necessary  for  the 
contraction,  but  that  the  stimulus  of  the  passing  urine  greatly 
increases  its  vigour. 

Continuity  of  the  duct  is  necessary  for  the  passage  of  the  wave 
of  contraction.  If  the  tube  is  partly  severed  and  fistulous  the 
contraction  passes  on  to  the  vesical  end ;  but  if  it  is  completely 
severed  the  lower  segment  no  longer  contracts. 

The  oblique  insertion  of  the  vesical  end  in  the  bladder  wall 
gives  it  a  valve  action  and  prevents  the  regurgitation  of  fluid 
from  the  bladder.  When  the  bladder  becomes  distended  the 
trigone  is  pushed  downwards  and  the  rest  of  the  bladder  wall  is 
stretched.  As  the  lower  end  of  the  ureter  is  inserted  into  the 
trigone  the  ureter  becomes  stretched  and  more  oblique.  As  a 
result   the   anterior   and   posterior   walls   are   approximated,   and 


XX] 


EXAMINATION   OF  URETER 


303 


the  intravesical  tension  presses  the  anterior  against  the  posterior 
wall,  further  occluding  the  lumen. 

Examination.  1.  Inspection. — I  have  once  seen  a  greatly 
distended  ureter  form  a  swelling  on  the  abdominal  surface  (Fig.  76). 
The  patient  was  a  girl  of  9,  admitted  to  my  ward  as  a  case  of 
intussusception.  The  abdomen  was  not  distended  or  rigid,  and  on 
the  left  side,  extending  from  the  left  lumbar  into  the  iliac  region 
and  disappearing  in  the  hypogastric  region,  was  a  large  sausage- 
like swelling,   very  evident   on  inspection  and  easily  traced  on 


Fig.  76. — Prominence  on  surface  of  abdomen  in  a  child 
caused  by  greatly  distended  left  ureter. 

palpation  upwards  into  the  left  hypochondrium  and  downwards 
into  the  pelvis.  On  rectal  examination  a  large  tense  mass  bulged 
into  the  rectum.  On  opening  the  abdomen  a  swelling  was  found 
to  the  outer  side  of  the  descending  colon,  and  proved  to  be  the 
greatly  distended  and  thickened  left  ureter,  leading  to  a  small 
hydronephrosis.  The  ureter  was  drained,  and  a  nephro-ureter- 
ectomy  performed  later. 

2.  Palpation. — (a)  On  deep  palpation  of  the  abdomen  in  a 
favourable  subject  a  thickened  ureter  can  be  felt  lying  alongside 
the  spinal  column.     It  is  most  readily  detected  as  it  crosses  the 


304 


THE   URETER 


[chap. 


brim  of  the  pelvis.  In  order  to  palpate  the  abdominal  portion  of 
the  ureter  (Fig.  77)  the  surgeon  stands  on  the  same  side  of  the 
patient  and  places  the  hands  fiat  on  the  abdomen,  the  lower  hand 
reaching  as  low  as  the  line  between  the  umbilicus  and  the  middle  of 
Poupart's  ligament,  the  upper  one  above  this  hand.  The  patient 
may  lie  flat,  or  with  the  knees  flexed,  and  respires  slowly  and 
deeply.  With  each  expiration  the  fingers  sink  into  the  abdomen 
in  the  line  of  the  ureter,  and  at  inspiration  they  hold  the  ground 
already  gained.  After  two  or  three  expirations  the  fingers  have 
sunk  to  the  back  of  the  abdomen  and  are  slowly  drawn  outwards. 


Fig.  77.- — Palpation  of  right  ureter. 

The  fingers  are  sunk  deeply  into  the  right  side  of  the  abdomen  and  are  palpating  the 
ureter  at  the  brim  of  the  pelvis. 

palpating  the  structures  which  roll  under  them.  No  attempt 
should  be  made  to  plunge  or  poke  the  fingers  into  the  abdomen 
against  the  inspiration  of  the  patient. 

The  ureter  is  most  readily  felt  in  tuberculosis  of  the  duct,  when 
it  may  resemble  a  leaden  gas-pipe,  and  can  be  felt  alongside  the 
vertebral  bodies  and  traced  over  the  brim  of  the  pelvis.  Occasion- 
ally, after  an  attack  of  renal  colic,  it  can  be  felt  thick  and  very 
tender,  and  when  it  is  dilated  and  thickened  in  urethral  obstruc- 
tion it  may  be  felt  on  careful  palpation. 

(6)  On  rectal  'palfotion  in  the  male  the  ureter  is  felt  above  and 
outside  the  base  of  the  prostate,  and  can  sometimes  be  hooked 
down  with  the  tip  of  the  finger.     The  finger  is  pushed  far  up 


XX]  EXAMINATION   OF   URETER  305 

beyond  the  base  of  tlie  prostate  and  then  passed  outwards  towards 
the  lateral  wall  of  the  pelvis. 

(c)  In  the  female  the  ureter  may  be  felt  in  the  vagina  in  the 
normal  state,  but  frequently  it  cannot  be  detected.  It  commences 
near  the  middle  line  on  the  anterior  vaginal  wall  and  passes  along 
the  lateral  wall  at  the  junction  of  the  middle  and  upper  thirds 
of  the  vagina.  About  3  in.  of  a  thickened  ureter  may  thus  be 
palpated.  The  tuberculous  ureter  is  readily  felt  as  a  thick,  hard, 
and  tender  cord  which  can  be  rolled  beneath  the  fingers,  and  it 
may  also  be  felt  in  other  conditions  of  chronic  ureteritis. 

3.  Cystoscopy. — On  cystoscopy  the  vesical  end  of  the  ureter 
can  be  examined  and  important  information  obtained. 

The  vesical  mucous  membrane  surrounding  the  orifice,  the 
shape  and  appearance  of  the  orifice  itself,  the  condition  of  the 
lips,  the  absence  or  presence  of  ureteric  contractions  and  their 
frequency  and  character,  the  presence  of  an  efflux  and  its  char- 
acters, should  all  be  noted.  An  account  of  these  will  be  found 
in  the  sections  dealing  with  Cystoscopy  (pp.  58,  364). 

4.  Catheterization  and  sounding  of  the  ureters.  —  By 
passing  a  catheter  up  each  ureter  into  the  renal  pelvis,  the  urine 
derived  from  the  corresponding  kidney  is  obtained  without  blend- 
ing with  that  of  the  other  kidney  and  without  passing  over  the 
surface  of  a  diseased  ureter  or  bladder.  The  tests  for  the  func- 
tion of  each  kidney  can  be  carried  out,  and  the  urines  examined 
for  changes  due  to  disease  or  loss  of  functional  power. 

The  ureter  may  be  sounded  by  passing  a  ureteric  catheter 
or  a  wax-tipped  bougie.  Information  in  regard  to  the  presence  or 
absence  of  stricture  or  calculus  is  thus  obtained.  When  a  stone 
is  present  the  catheter  may  be  arrested,  or  it  may  hesitate  and 
then  pass  on.  The  size  of  the  calculus  is  not  important  in  regard 
to  the  passage  of  the  instrument ;  a  very  large  calculus  may  per- 
mit the  catheter  to  slip  past,  while  a  small  calculus  may  arrest 
it.  Wax-tipped  bougies  are  only  useful  in  the  female  subject,  in 
whom  Kelly's  open  cystoscopic  tubes  can  be  used.  These  methods 
are  referred  to  in  the  chapter  on  Stone  in  the  Ureter  (p.  328). 

5.  Radiography. — The  X-rays  may  in  rare  cases  show  the 
shadow  of  a  greatly  distended  and  thickened  ureter. 

Calculi  in  the  ureter  throw  a  shadow  in  the  line  of  the  duct. 
It  is  very  important  to  define  the  course  of  the  ureter  in  cases 
of  suspected  calculus,  and  this  is  done  by  passing  up  the  ureter  a 
bougie  opaque  to  the  X-rays,  and  obtaining  a  radiogram. 

The  line  of  the  ureter  shown  by  radiography. — In  examining  the 
ureter  by  the  X-rays  it  is  of  the  utmost  importance,  as  Ironside 
Bruce  has  shown,  to  use  a  fixed  position  of  the  relations  of  the 
u 


306  THE   URETER  [chap. 

patient  to  the  source  of  light.  For  this  there  are  two  reasons : 
(1)  The  line  of  the  ureter  is  shown  in  its  relation  to  the  bony 
skeleton,  and  variation  in  the  position  of  the  source  of  light  causes 
changes  in  the  relations  of  the  shadow  of  the  ureter  with  those 
of  the  bones.  (2)  When  a  stone  is  descending  the  ureter  slight 
changes  in  the  position  can  only  be  detected  by  reproducing  with 
mathematical  exactness  at  subsequent  visits  the  previous  posi- 
tions of  the  patient  and  of  the  source  of  light. 

The  fixed  positions  suggested  by  Ironside  Bruce  are — (1)  In 
the  abdominal  and  sacral  segments  "  the  anode  of  the  X-ray 
tube  is  placed  immediately  below  the  spine  of  the  2nd  lumbar 
vertebra."  (2)  In  the  pelvic  and  sacral  segments  the  source  of 
light  is  opposite  the  upper  border  of  the  pubic  symphysis. 

There  are  three  segments  of  the  ureter  which  are  important 
in  reading  a  radiographic  plate  : — 

1.  The  abdominal  segment,  which  extends  from  the  renal  pelvis 
to  the  upper  border  of  the  shadow  cast  by  the  bones  of  the  pelvis, 
here  the  lateral  mass  of  the  sacrum. 

2.  The  segment  in  the  broad  band  of  shadow  thrown  by  the 
lateral  mass  of  the  sacrum. 

3.  The  pelvic  segment  of  the  ureter. 

1.  Abdominal  segment. — The  ureter  commences  in  the  renal 
pelvis  at  the  tip  of  the  transverse  process  of  the  2nd  lumbar  ver- 
tebra. From  this  point  the  duct  passes  inwards  and  downwards 
upon  the  psoas  muscle,  crossing  the  tip  of  the  transverse  process 
of  the  3rd  lumbar  vertebra  and  inclining  inwards  to  cross  the 
transverse  process  of  the  4th  lumbar  vertebra  near  its  base  and 
the  transverse  process  of  the  5th  lumbar  vertebra  close  to  the 
body.     (Plate  21,  Fig.  1.) 

2.  Sacral  segment. — The  ureter  then  passes  vertically  along  the 
lateral  mass  of  the  sacrum  as  it  crosses  the  brim  of  the  pelvis, 
well  internally  to  the  sacro-iliac  synchondrosis. 

3.  Pelvic  segment. — After  crossing  the  brim  the  ureter  curves 
outwards  across  the  outer  border  of  the  sacrum,  and  now  lies 
within  the  ring  of  the  shadow  thrown  by  the  brim  of  the  pelvis. 
It  crosses  the  tip  of  the  spine  of  the  ischium  and,  keeping  just 
internally  to  the  shadow  of  the  pelvic  ring,  swings  inwards.  It 
may  then  become  hidden  behind  the  horizontal  ramus  of  the 
pubic  bone,  but  more  frequently  it  passes  above  the  upper  border 
of  this  bone,  and  reaches  almost  to  the  middle  line.  (Plate  21, 
Fig.  2.) 

This  is  the  appearance  most  commonly  found,  but  there  are 
cases  where  the  course  is  different.  This  variation  in  the  course 
of  the  ureter  as  shown  in  a  radiogram  does  not  depend    upon 


2   ^ 
o 

.S  -c 
5   " 


c    o 


-   ^ 


O    "oc 


si 


«^fc^ 


3   a  2    IS 

—     3     cB     o 


■^    E   S 


^    >. 


O.  'OC    in 
m     o     n 


XX]  URETERAL   RADIOGRAPHY  307 

changes  in  the  position  of  the  source  of  the  rays  or  the  patient, 
as  these  radiograms  were  taken  in  the  "  fixed  position." 

(i.)  The  ureter  may  lie  nearer  the  middle  line,  and  is  partly 
obscured  by  the  shadow  of  the  vertebral  bodies,  (ii.)  It  may  lie 
farther  out  beyond  the  tips  of  the  transverse  processes  and  pass 
outwards  from  the  shadow  of  the  psoas  muscle  at  the  level  of 
the  3rd  lumbar  vertebra,  (iii.)  It  passes  upwards  and  outwards 
away  from  the  vertebral  colunm  at  the  level  of  the  4th  lumbar 
vertebra. 

These  variations  may  be  partly  accounted  for  by  an  abnormally 
placed  or  movable  kidney,  and  it  is  likely  that  the  less  pronounced 
changes  in  the  line  of  the  ureter  result  from  temporary  outward 
displacement  of  the  kidney  by  the  compressor  used  during  the 
radiography.  The  varying  tilt  of  the  pelvis  also  shghtly  affects 
the  radiographic  position  of  the  pelvic  ureter. 


CHAPTER  XXI 

INJURIES  OF  THE  URETER 

From  its  protected  position  and  the  comparative  thickness  and 
elasticity  of  its  wall  the  ureter  is  less  liable  to  injury  by  violence 
than  the  kidney  or  other  abdominal  organs.  In  1901,  Morris 
could  find  only  12  probable  cases  in  the  literature,  and  but  3  of 
these  were  actually  proved  to  be  ruptures  of  the  ureter. 

With  the  progress  of  modern  surgery  a  new  and  more  numerous 
class  of  cases  has  appeared,  namely,  injury  to  the  ureter  during 
surgical  operations  upon  the  ureter  or  on  neighbouring  structures. 

1.  Subcutaneous  Injuries  and  Penetrating  Wounds 

Etiology. — Compression  between  hard  bodies,  kicks,  falls  on 
the  loin,  and  being  run  over  by  a  wheel  are  the  forms  of  Adolence 
which  have  caused  rupture  of  the  ureter.  Rowlands  records  the 
case  of  a  young  man  who,  walking  with  his  left  hand  in  his  pocket, 
fell  upon  the  left  elbow  and  ruptured  the  left  ureter  at  its  upper 
end.  Impaction  against  the  transverse  processes  of  the  lumbar 
vertebrae  and  overstretching  of  the  ureter  are  the  mechanisms 
which  are  believed  to  produce  the  rupture.  Only  a  few  cases  of 
bullet  wounds  and  punctured  wounds  by  a  rapier  are  on  record. 

Pathology. — In  1  out  of  12  cases  the  peritoneum  over  the 
ureter  was  ruptured  (Morris). 

The  ureter  may  be  bruised  and  cicatricial  contraction  follow ; 
or  it  may  be  torn  longitudinally,  or  be  torn  across. 

If  the  ureter  be  partly  or  completely  torn  an  accumulation 
of  urine  forms  in  the  retroperitoneal  space,  which  may  later  rup- 
ture into  the  colon.  If  the  peritoneum  be  torn,  urine  leaks  into 
the  peritoneal  cavity. 

Symptoms. — If  the  ureter  alone  be  injured  there  is  sHght 
haemorrhage,  or  this  may  be  completely  absent.  There  are  pain 
and  tenderness,  which,  however,  are  difficult  to  distinguish  from 
those  which  may  follow  a  blow  without  rupture  of  the  ureter, 
and  which  usually  pass  off  in  a  few  days.  If  the  patient  survive 
the  injury  a  swelling  forms  in  the  loin.     This  may  appear  a  few 

308 


CHAP.  XXI]  INJURIES   OF  URETER  309 

days  after  tlic  iiijuiy,  or  it  may  bo  delayed  for  several  weeks.  It 
is  rounded  or  elongated  and  well  defined,  and  may  assume  a  large 
size.  This  is  due  to  accumulation  of  urine  and  blood  in  the  retro- 
peritoneal tissues.  Sui)purati()n  takes  place,  and  the  symptoms 
of  extensive  suppuration  develop. 

It  is  impossible  to  diagnose  between  rupture  of  the  ureter 
and  rupture  of  the  renal  pelvis.  If  the  patient  recovers  after 
receiving  a  penetrating  wound  of  the  ureter  a  urinary  fistula  forms. 

Prognosis. — When  early  operation  is  performed  the  prognosis 
is  good.     When  the  peritoneum  is  ruptured  it  is  more  serious. 

Treatment. — In  most  of  the  cases  recorded,  puncture  of  the 
swelling  and  incision  and  drainage  were  the  methods  of  treatment 
adopted.  The  real  difficulties  are  met  with  in  making  an  early 
diagnosis  and  in  finding  the  ruptured  ureter  in  a  large  mass  of 
inflammatory  tissue.  A  swelling  of  the  loin  following  an  injury 
in  this  region  should  be  freely  exposed  by  a  lumbar  or  a  lumbo- 
abdominal  incision,  when  the  presence  of  urine  in  the  fluid  will 
lead  to  a  careful  examination  of  the  renal  pelvis  and  ureter.  Should 
the  history  of  haematuria,  however  shght,  or  the  position  of  the 
swelling  have  led  to  a  suspicion  of  the  nature  of  the  injury,  a 
catheter  should  be  passed  up  the  ureter  before  the  operation,  and 
vidll  help  in  the  identification  of  the  tube.  When  the  ruptured 
ends  are  found,  one  of  the  methods  of  ureteral  anastomosis  should 
be  practised. 

In  a  case  recorded  by  Vaughan  of  a  gunshot  wound  of  the 
ureter,  an  implantation  of  the  end  of  the  ruptured  ureter  into 
the  bladder  was  successful. 

Nephrectomy  may  be  required  in  rare  cases  for  septic  com- 
plications or  for  the  cure  of  an  intractable  fistula. 

LITERATURE 

Allingham,  Brit.  Med.  Journ.,  1891,  i.  699. 

Barker,  Lancet,  Jan.  17,  1885. 

Morris,  Hunterian  Lectures,   1908. 

Page,  Ami.  Surg.,  1894. 

Rowlands,  Med.  Press  Circ,  April  21,  1909. 

Vaughan,  Amer.  Journ.  Med.  Sci.,  1905,  p.  499. 

2.  Surgical  Wounds 

Injury  to  the  ureter  is  occasionally  caused  by  forceps  during 
delivery,  but  the  most  frequent  form  of  surgical  wound  of  the 
duct  is  made  during  pelvic  operations,  and  above  all  in  gynae- 
cological operations.  The  removal  of  mahgnant  growths  of  the 
uterus  by  the  extensive  operations  now  in  vogue  is  a  prolific 
source  of  accidental  wounds  of  the  ureter. 


310  THE   URETER  [chap. 

The  ureter  may  be  partly  or  completely  cut,  or  its  wall  or  blood 
supply  may  be  damaged  by  extensive  stripping  or  by  pressure 
or  by  rough  handling,  so  that  it  sloughs  and  a  fistula  forms  after 
some  days.  The  fistula  may  open  in  the  vagina,  or,  if  a  subtotal 
excision  of  the  uterus  has  been  performed,  in  the  cervix  or  on  the 
skin  surface  at  the  abdominal  wound. 

Spontaneous  closure  of  such  a  fistula  has  taken  place,  but  it 
is  so  rare  as  not  to  be  looked  for. 

Treatment. — The  treatment  of  such  accidents  is  either  imme- 
diate at  the  time  of  the  operation,  or  remote  when  a  fistula  has 
formed.     The  treatment  of  fistula  will  be  described  later. 

1.  Partial  laceration  or  incision  of  the  ureter.— The  ureter  heals 
well  if  the  blood  supply  has  not  been  damaged  by  extensive  strip- 
ping and  rough  handling.  The  edges  of  the  wound  should  be 
carefully  sutured  with  fine  catgut.  A  ureteral  catheter  may  be 
passed  up  the  ureter  to  the  renal  pelvis  from  the  bladder,  and 
retained  for  a  week.  A  covering  of  fatty  or  areolar  tissue  or  even 
of  peritoneum  should  be  applied  over  the  ureter  wound  to  assist 
healing.  Provision  should  be  made  for  drainage  of  the  urine 
should  leakage  occur.  If  there  be  an  irregular  tear  of  the  ureter 
it  is  better  to  resect  a  portion  of  the  tube  and  perform  one  of  the 
operations  for  anastomosis. 

2.  Complete  laceration  or  section  of  the  ureter. — Ureteral  anasto- 
mosis should  be  carried  out. 

The  varieties  of  anastomosis  are  as  follows  : — 
■      (1)  End-to-end  anastomosis,     {a)  The  ends  are  cut  transversely 
(Schopf)  ;    (b)  the  ends  are  cut  obliquely  (Bovee).     The  objection 
to  this  is  that  it  leaves  a  ridge  in  the  lumen  which  promotes 
stricture  formation. 

(2)  End-to-end  anastomosis  with  invagination  (Poggi).  This 
is  facilitated  by  splitting  one  end  and  invaginating  the  other 
(D'Antona). 

(3)  The  employment  of  a  button  (Boari)  or  a  tube  of  magne- 
sium over  which  the  ends  are  drawn  and  invaginated.  The  tube 
is  dissolved  by  the  urine  in  twenty  days  (Taddei). 

(4)  End-to-side  anastomosis,  in  which  one  end  is  ligatured 
and  the  edges  of  the  other  end  sutured  to  the  edges  of  a  longi- 
tudinal wound  in  the  lateral  wall  of  the  first,  or  cut  obliquely  and 
invaginated  into  it  (Van  Hook). 

(5)  Lateral  anastomosis,  in  which  both  ends  are  ligatured  and 
the  edges  of  a  longitudinal  lateral  wound  in  each  ureter  are  united 
in  a  manner  similar  to  that  used  in  intestinal  anastomosis  (Monari). 

The  peritoneum  should  be  closed  outside  the  junction  to  prevent 
extraperitoneal  extravasation.     The  junction  may  be  covered  with 


XXI]     WOUNDS   OF   URETER  :   TREATMENT       311 

a  litxp  of  peiitDiK'uiu  or  a  j^rai't  of  oiiicntiim.  A  ureteial  catheter 
may  be  passed  from  the  bladder  up  the  ureter,  but  this  is  likely 
to  cause  irritation  and  is  better  omitted. 

When  a  portion  of  the  ureter  has  been  torn  away,  one  of  the 
following  procedures  may  be  carried  out : — 

(1)  Uretero-cysto-neostomy,  the  upper  end  of  the  ureter  being 
implanted  into  some  part  of  the  bladder.  Here  the  rupture  must 
be  low  down  and  the  upper  segment  sufficiently  long  to  reach  the 
bladder  (Novaro). 

(2)  Uretero-ureteral  anastomosis,  the  two  ureters  being  exposed 
by  reflecting  the  peritoneum  on  the  front  of  the  promontory,  and 
the  end  of  the  damaged  ureter  ligatured  and  brought  across  the 
middle  line  and  united  to  the  uninjured  ureter  by  lateral  anasto- 
mosis (Bernasconi  and  Colombino). 

(3)  The  formation  of  a  cutaneous  fistula  by  suture  of  the 
severed  end  to  the  skin. 

(4)  Implantation  into  the  intestine. 

(5)  Immediate  nephrectomy. 

(6)  Ligature  of  the  upper  end  of  the  ureter  has  been  suggested, 
with  the  object  of  causing  atrophy  of  the  kidney. 

Results. — Alksne  collected  all  the  published  records  of  ureteral 
anastomosis  since  1886,  and  found  43  complete  recoveries  in  60 
cases,  9  recoveries  after  temporary  fistula,  and  8  deaths  (11-6 
per  cent.). 

Poggi's  invagination  method  gave  the  best  results,  yielding 
12  per  cent,  of  fistulas  in  28  cases,  while  the  circular  method  gave 
24  per  cent,  of  fistulse. 

LITERATURE 

Alksne,   Folia    Urol,  1908,  p.  280. 

Baja,  These  de  Paris,  1908. 

Bernaseoni  et  Colombino,  Ann.  d.  Mai.  d.  Org.  Gen.-  TJrin.,  1905,  ii.  1361. 

Boari,  11  Polidinico,  July  15,  1899  ;    Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1908, 

ii.   1761. 
Bovee,   Ann.  Surg.,  1900,  p.  165. 
Hein,  Jahresh.  d.   Urogen.  Afptirates,  1906,  ii.  126. 
Markoe  and  Wood,  ^«m.  Surg.,  1899. 
Poggi,  XlXe  Congres  de  Chir.,  Paris,  1906,  p.  188. 
Scharpe,  Ann.  Surg.,  1906,  p.  687. 


CHAPTER  XXII 

CONGENITAL  ABNORMALITIES  OF  THE   URETER 
PROLAPSE— FISTULA 

CONGENITAL   ABNORMALITIES 

Anomalies  of  number. — The  ureter  is  sometimes  divided  so 
that  there  are  two  ducts,  and  this  may  extend  from  the  pelvis  to 
the  bladder  (Fig.  78).  The  two  tubes  may  unite  to  form  a  single 
lumen  just  before  entering  the  bladder,  or  two  distinct  ureters  may 
pierce  the  bladder  wall  and  open  separately.  The  ureter  which 
drains  the  upper  part  of  the  kidney  usually  crosses  that  from  the 
lower  part  and  opens  lower  on  the  trigone.  In  such  a  case  there 
are  two  physiologically  separate  kidneys  on  one  side,  although  no 
anatomical  division  may  be  apparent.  Sometimes  a  deep  groove 
on  the  surface  of  the  organ  indicates  the  division.  One  portion  of 
the  kidney  may  be  diseased  and  the  other  remain  normal. 

In  routine  cystoscopy  the  discovery  of  two  ureteric  orifices 
lying  side  by  side  on  the  horn  of  the  trigone  is  comparatively 
frequent  (Fig.  79),  and  an  efflux  may  be  seen  from  each  opening. 
An  opaque  bougie  can  be  passed  up  one,  or  sometimes  both,  and 
the  double  ureter  demonstrated  by  means  of  the  X-rays.  The 
illustration  of  a  double  ureter  (Plate  21,  Fig.  3)  was  derived  from 
a  patient  who  had  been  treated  for  a  urethral  stricture,  and 
subsequent  cystoscopy  revealed  the  double  ureter.  The  frequency 
of  double  ureter  is  about  4  per  cent,  of  cases  (Lessig).  Calculus 
is  often  found  in  kidneys  which  have  a  double  pelvis  and  ureter. 
Bilateral  double  ureters  are  less  frequent  than  unilateral. 

Five  or  even  six  ureters  have  been  observed  in  one  individual. 
Absence  of  a  ureter  is  combined  with  absence  of  the  kidney.  In 
a  case  of  fused  kidney  with  two  ureters  one  duct  may  cross  the 
middle  line  and  open  on  the  opposite  side  of  the  trigone. 

Abnormalities  of  position. — When  a  single  ureter  is  present 
and  opens  into  the  bladder  the  orifice  is  frequently  misplaced, 
usually  towards  the  middle  line.  I  have  seen  a  single  ureter,  in 
the  lower  end  of  which  a  stone  was  impacted,  open  in  the  middle 
line  of  the  trigone.     The  ureter  may  open  into  the  prostatic  urethra 

312 


CHAP.  XXII]    ABNORMALITIES  OF   URETER 


313 


in  the  male  or  the  urethra  in  the  female.  It  has  been  found  to 
open  into  the  seminal  vesicles,  the  vagina,  or  the  rectum.  The 
displaced  opening  is  frequently  that  of  a  supernumerary  ureter. 


Fig.  78. — Double  right  ureter  draining  upper  and  lower  halves 

of  kidney. 

Case  of  septic  pyelonephritis  complicating  vesical,  ureteral,  and  renal  calculi  ;  chronic  cystitis  and 

hypertrophy  of  bladder.  Lower  half  of  right  kidney  destroyed  by  calculus,  upper  half  shows  recent 

pyelonephritis  ;  calculus  in  left  ureter ;  commencing  distension  of  left  kidney. 

Out   of   9  cases  recorded  by   Schwarz   where  the  ureter  opened 
into  the  prostatic  urethra,  there  were  double  ureters  in  7.     The 


314 


THE   URETER 


[chap. 


abnormally  placed  orifice  is  frequently  narrowed  so  as  to  cause 
dilatation  of  the  ureter  and  corresponding  kidney.  Sometimes 
a  misplaced  ureter  ends  blindly  in  the  bladder  wall  and  forms  a 
cyst.  Nebel  has  recorded  the  termination  of  the  ureters  on  the 
surface  of  the  abdomen  between  the  umbilicus  and  the  pubes. 
According  to  Schwarz  the  diagnostic  sign  of  a  ureter  opening  into 
the  female  urethra  is  incontinence  of  urine — the  urine  dribbling 
away  from  the  urethra,  while  the  patient  can  pass  a  quantity  of 
urine  voluntarily.  The  ureter  has  been  transplanted  into  the 
bladder  in  such  cases. 

Congenital    narrowing   of    the   ureter. — I    have    observed 

congenital  narrowing  of  the 
ureteric  orifices  in  a  man  whose 
urinary  system  was  otherwise 
normal.  The  finest  ureteric  cath- 
eter or  bougie  would  not  pass 
through  the  orifices.  The  lu- 
men of  the  ureter  may  be  nar- 
rowed or  completely  blocked  by 
a  valve  or  congenital  stricture. 
As  a  result,  either  hydrone- 
phrosis develops  or  atrophy  of 
the  kidney  ensues.  Rarely  the 
ureter  immediately  above  the 
stricture  dilates  without  disten- 
sion of  the  renal  pelvis  and 
kidney.  The  ureter  may  be 
compressed  by  an  artery  or  vein 
which  takes  an  abnormal  course  {see  under  Hydronephrosis,  p.  168). 

LITERATURE 

Blumer,   Johns  Hopkins  Hosp.  Bull.,  1896,  p.  175. 

Israel,  Bed.  klin.   Woch.,  Feb.  27,  1900. 

Lessig,   Charite.  Ann.,  xxx.  452. 

Lewis,  Brandsford,  Med.  Bee,  1906,  p.  521. 

Meyer,  Vir chows  Arch.,  1907,  p.  408. 

Schwarz,  Beitr.  z.  Idin.  Chir.,  1895,  Bd.  xv. 

Walker,  Thomson,   Renal  Function  in  Urinary  Surgery.     1908. 

Zondek,  Zur  Chirurgie  der  Ureteren.     Berlin,  1905. 


Fig.  79. — Double  ureteric 
orifice  on  left  side. 


PROLAPSE   OF   THE   URETER      ' 

Under  the  term  prolapse  of  the  ureter  two  conditions  are 
included  which  it  is  impossible  to  distinguish  clinically.  In  one 
there  is  prolapse  of  the  whole  thickness  of  the  ureteral  wall,  ana- 
logous to  prolapse  of  the  rectum ;  in  the  other  there  is  prolapse  of 
the  mucous  membrane  alone. 


XXII]  PROLAPSE   OF   URETER  315 

Pathology.  —The  tumour  is  a  "^'lohulai'  oi'  sausage-shaped 
cyst  attaclicd  by  a  narrower  base  in  the  positujii  of  the  ureteric 
orifice.  It  varies  in  size  from  a  pea  to  a  wahiut,  or  even  larger. 
The  cyst  consists  of  a  double  layer  of  mucous  membrane,  the 
bladder  mucosa  externally  and  the  ureteral  mucosa  internally. 
At  some  part  of  the  surface,  usually  the  summit  of  the  swelling,  the 
ureteric  orifice  can  be  found.  It  is  small,  and  may  be  stenosed 
or  completely  obliterated.  In  some  cases  one  or  several  small 
calculi  have  been  found  in  the  cavity.  The  cyst  is  usually  single, 
but  Portner  found  that  of  40  cases  5  were  bilateral.  I  have 
examined  two  cases  with  the  cystoscope  ;  in  one  both  ureteric 
orifices  were  affected,  one  to  a  greater  degree  than  the  other,  and 
in  the  second  case  the  condition  affected  both  orifices  equally. 
(Plate  22,  Fig.  1.)  In  some  cases  the  cyst  has  prolapsed  into  the 
urethra  and  appeared  at  the  external  meatus  in  the  female.  Neelsen 
described  a  case  in  which  the  cyst  was  strangulated  by  the  vesical 
sphincter  and  became  necrotic.  The  condition  may  result  from 
a  congenital  narrowing  of  the  ureteric  orifice  or  an  acquired  stenosis 
from  ureteritis.  Calculi  may  be  present  in  the  cystic  ureter.  In 
a  number  of  cases  there  has  been  a  double  ureter  on  the  diseased 
side. 

Symptoms. — The  symptoms  are  irregular.  In  some  cases 
renal  symptoms  have  been  present,  such  as  lumbar  pain  and  pain 
in  one  or  both  ureters.  More  frequently  there  are  symptoms  of 
vesical  irritation  or  obstruction,  such  as  frequent  micturition, 
scalding  pain  along  the  urethra,  terminal  haematuria,  difficult  mic- 
turition, and  occasional  intermittent  passage  of  urine  or  attacks 
of  complete  retention.  Attacks  of  hsematuria  may  be  the  only 
symptom.  The  ureter  and  kidney  are  frequently  dilated  on  the 
affected  side.  Infection  of  the  kidney  may  supervene.  The  con- 
dition may  be  latent  for  a  considerable  period.  The  cyst  may 
appear  at  the  external  meatus  in  the  female,  and  can  be  distin- 
guished from  prolapse  of  the  bladder  by  passing  a  catheter  into 
the  bladder  and  drawing  off  the  urine. 

The  diagnosis  is  made  with  the  cystoscope.  In  the  position 
of  the  ureteric  orifice  a  rounded,  globular,  or  sausage-shaped 
swelling  is  seen,  pink  and  semi-translucent  in  appearance.  In  a 
prolapse  of  the  mucosa  alone  delicate  blood-vessels  can  be  seen 
coursing  over  the  cyst,  while  in  a  prolapse  of  the  whole  thickness  of 
the  wall  the  vessels  are  abruptly  arrested  at  the  base  (Kapsammer). 
In  two  cases  that  I  have  seen,  the  cysts  gradually  filled  up 
under  observation,  becoming  pale  and  more  transparent  until 
they  reached  a  large  size,  and  then  slowly  subsiding  like  an  air 
balloon  ;    and  this  was  repeated  in  slow,  regular  rhythm. 


316  THE   URETER  [chap. 

In  one  of  these  cases  the  condition  was  equally  developed  on 
both  sides,  the  left  cyst  being  covered  with  small  translucent  cysts. 
On  removal  of  the  cysts  I  found  both  ureters  dilated. 

Treatment. — Before  operation  the  kidneys  and  ureters  should 
be  searched  with  the  X-rays  for  stone. 

The  pouch  is  cut  off  at  the  base  with  scissors  and  removed, 
with  any  calculi  it  may  contain. 

Operation  by  the  urethra  with  cutting  forceps  or  the  cautery 
in  the  female  has  been  successful.  Removal  by  suprapubic  cyst- 
otomy is  preferable. 

LITERATURE 

Englisch,   Centralhl.  f.   Kranlch.  d.  Ham-  u.  Sex.- Org.,  1898,  ix.  7. 

Fenwick,   Obscure  Diseases  of  the   Kidney.     1903. 

Freyer,   Trans.   Roy.  Med.  and   Chir.  Soc,  1897. 

Grosglik,  Zeits.  f.    Urol,  1901,  p.  577. 

Kapsammer,  Zeits.  f.   Urol.,  1908,  p.  800. 

Kolisko,  Wien.  Bin.  Woch.,  1889,  No.  48. 

Portner,  Monats.  f.   Urol.,  1904,  ix.  5. 

FISTULA  OF   THE   UEETEE, 

Fistula  may  follow  an  operation  for  stone  in  the  ureter,  the 
external  opening  being  in  the  scar  of  the  operation.  Uretero- 
vaginal  fistula  is  more  common.  Rarely  it  is  congenital ;  fre- 
quently it  is  acquired  and  follows  parturition,  in  which  case  it 
involves  the  bladder,  ureter,  and  vagina  (uretero-vesico-vaginal 
fistula) ;  or  it  may  result  from  a  surgical  operation  on  the  uterus 
and  involve  the  ureter  and  vagina  only,  the  opening  in  the  ureter 
being  at  some  distance  (5  cm. — Bazy)  from  the  bladder.  The  ureter 
may  be  partly  or  completely  severed.  On  the  vesical  side  of  the 
fistula  there  is  almost  invariably  stenosis  of  the  ureter.  Above 
the  fistula  the  ureter  may  be  dilated,  and  the  kidney  is  also  dilated. 
The  fistula  very  rarely  closes  spontaneously. 

Infection  of  the  fistula,  ureter,  and  kidney  is  the  rule. 

Before  operating  upon  a  ureteral  fistula  it  is  necessary  to 
ascertain — 

(1)  Is  the  duct  partly  or  comfletdy  severed  ?  On  examination  of 
the  bladder  with  the  cystoscope  the  ureteric  orifice  shows  no  move- 
ment where  the  ureter  is  completely  severed,  but  there  is  rhythmic 
contraction  of  the  ureteric  orifice  if  the  ureter  is  only  partly  severed. 

(2)  7s  the  fistula  vesical  or  ureteral?  By  injecting  methylene- 
blue  solution  into  the  bladder  the  blue  fluid  escapes  by  the 
fistula  if  the  fistula  communicates  with  the  bladder,  but  not  if 
the  fistula  is  purely  ureteral. 

Examination  with  the  cystoscope  will  show  a  healthy  bladder 
when  the  ureter  is  fistulous. 


xx.i]  FISTULA   OF  URETER  317 

(3)  Which  ureter  is  fistulous  ?  Where  the  ureter  has  been 
completely  severed,  cystoscopic  examination  will  show  one  ureter 
motionless  and  without  efflux,  and  the  subcutaneous  injection 
of  4  c.c.  of  a  4  per  cent,  solution  of  indigo-carmine  is  followed 
by  the  appearance  of  a  coloured  efflux  at  the  healthy  ureter  and 
no  efflux  at  the  other.  Regular  powerful  contractions  of  the 
ureteric  orifice  are  observed  when  the  fistula  is  low  down  and 
the  duct  is  not  completely  severed.  There  is,  however,  no  efflux 
from  the  orifice. 

(4)  What  is  the  position  of  the  fistula  ?  This  is  ascertained  by 
sounding  the  ureter  with  a  bougie  opaque  to  the  X-rays.  The 
bougie  is  arrested  at  the  stricture  below  the  fistula,  and  the  dis- 
tance from  the  bladder  ascertained  by  observing  the  markings  on 
the  bougie  and  by  obtaining  a  radiogram. 

Treatment.  1.  Introduction  of  a  catheter  en  demeure. — 
This  is  impossible  in  a  large  proportion  of  cases  on  account  of  the 
stricture  of  the  ureter.  It  has  been  practised  in  a  few  cases, 
but  the  ultimate  result  has  not  been  successful.  The  stricture 
recontracts  and  the  fistula  opens  after  the  catheter  has  been  re- 
moved, or  the  fistula  may  heal  permanently  and  the  recontraction 
of  the  stricture  brings  .about  atrophy  of  the  kidney. 

2.  Suture  of  the  ureter. — This  is  not  feasible.  The  patent 
segments  of  the  ureter  are  widely  separated  by  a  mass  of  fibrous 
tissue,  and  it  is  impossible  to  approximate  them. 

3.  Transplantation  of  the  ureter,  i.  Implantation  into  the 
bladder  {uretero-cysto-neostomy). — This  may  be  done  by  a  trans- 
peritoneal operation  or  by  the  extraperitoneal  route.  Legueu 
recommends  that  the  abdomen  be  opened  and  the  position  of 
the  ureter  ascertained.  The  peritoneum  is  then  closed  and  the 
operation  performed  extraperitoneally.  The  urine  is  invariably 
infected  in  these  cases,  so  that  the  extraperitoneal  route  is  to  be 
preferred. 

The  ureter  is  followed  downwards  as  low  as  possible  and  cut 
across  above  the  fistula.'  An  opening  is  made  in  the  most  accessible 
part  of  the  bladder,  and  the  union  of  the  ureter  and  bladder  made 
at  this  point.  It  is  essential  that  no  traction  be  exerted  on  the 
newly  formed  union,  and  the  ureter  and  bladder  should  be  freed. 
Ricard  sutures  the  wall  of  the  bladder  to  the  pelvic  peritoneum 
to  prevent  traction.  Many  varieties  of  implantation  have  been 
used  (p.  339). 

Results  of  uretero-cysto-neostomy. — ^Primary  miion  is  occasion- 
ally obtained,  but  frequently  there  is  leakage  of  urine.  A  few 
cases  have  been  recorded  in  which  by  catheterization  of  the 
implanted   ureter   a   successful   result   has   been   confirmed   after 


318  THE   URETER  [chap,  xxii 

considerable  periods,  but  in  other  cases  the  kidney  has  been  found 
atrophied  post  mortem. 

ii.  Implantation  into  the  bowel. — On  the  right  side  the  caecum 
or  ascending  colon  is  selected,  on  the  left  the  pelvic  portion  of 
the  colon.     (For  a  description  of  the  operation,  see  p.  342.) 

Results  of  implantation  into  the  bowel. — Successful  results 
have  been  published.  The  mucous  membrane  of  the  colon  does 
not  resent  the  action  of  the  urine,  and  the  fluid  is  passed  with 
the  faeces. 

The  dangers  of  the  operation  are  shock,  peritonitis,  and  ascend- 
ing pyelonephritis  from  infection. 

Papin  found  a  mortality  from  the  operation  of  58  per  cent, 
where  bilateral  implantation  was  performed,  and  29  per  cent. 
where  one  ureter  only  was  implanted.  A  few  cases  have  been 
recorded  in  which  the  patient  continued  in  good  health,  but  many 
patients  die  within  a  comparatively  limited  period  of  ascending 
pyelonephritis. 

iii.  Lateral  anastomosis  of  the  upper  segment  of  the  injured 
ureter  with  the  opposite  ureter  has  been  performed  experimentally 
by  Bernasconi  and  Colombino  for  injuries  of  the  ureter.  The  ureters 
are  exposed  by  reflecting  the  peritoneum  over  the  promontory,  and 
lateral  anastomosis  carried  out.  The  method  has  not  yet  emerged 
from  the  experimental  stage. 

4.  Where  the  fistula  opens  high  up  in  the  vagina  an  operation 
may  be  performed  which  turns  a  small  portion  of  the  vagina 
into  the  bladder.  The  fistula  is  enlarged,  and  an  opening  made 
into  the  bladder  close  to  it.  This  part  of  the  vagina  is  then 
closed  off  so  that  the  fistula  and  bladder  become  continuous. 

5.  The  vagina  may  be  obliterated  after  first  establishing  a 
large  vesico- vaginal  fistula. 

6.  Ligature  of  the  ureter  with  the  object  of  producing 
atrophy  of  the  kidney  was  suggested  by  Guyon. 

7.  Nephrectomy  has  until  recently  been  resorted  to  by  a 
large  number  of  surgeons.  It  should  not  be  performed  until 
a  plastic  operation  has  been  tried,  or  unless  septic  pyelonephritis 
is  present. 

LITERATURE 

Bernasconi  et  Colombino,  Ann.  d.  Mai.  d.  Org.  Gai.-Urin. 

1905,  ii.   1361. 
Boari,  Ann.  d.  Mai.  d.   Org.   Gen.-  Urin.,  1909,  ii.   1232. 
Budinger,  Arch.  f.  klin.  Ghir.,  1894,  p.  639. 
Legueu,   Traite  Chir.  d' Urol.,  1910,  p.  1172. 
Payne,  Journ.  Amer.  Med.  Assoc,  1908,  p.  1321. 
Scharpe,  An7i.  Surg.,  1906,  p.  687. 
Tuffier  et  Levi,  Ann.  de  Gyn.  et  d'Ohst.,  1895,  p.  382. 


CHAPTER  XXIII 


STONE  IN  THE  URETER 

The  great  majority  of  calculi  in  the  ureter  are  formed  in  the  renal 
pelvis  and  passed  into  the  ureter.     Very  rarely  a  calculus  is  formed 
in  the  ureter  itself.     In  a  man  from  whose  right  ureter  I  had 
removed  a  calculus  impacted  at  the  brim  of  the  pelvis,  I  closed 
the  ureteric  wound  with  fine 
silk.      Six    months    later    he 
passed  a  smooth  oval  calculus 
with   one   silk    suture   and   a 
facet,   and  after   another   six 
months   he   passed   a   second 
calculus  articulating  with  the 
first   and    containing    the  re- 
maining ■  three   silk  sutures  I 
had    placed    in    the    ureter. 
(Fig.    80.)      Primary     calculi 
have  also  been  found  on  other 
forms   of    foreign  body,  such 
as  a  catheter  or  a  pin  (Boyer), 
or  on  an  ulcerated  surface. 

The  etiology  of  secondary 
ureteric  calculus  is  that  of 
renal  calcuH  (p.  249). 

Pathology. — Ureteral  cal- 
culi are  either  impacted  or 
migrating.  A  stone  migrating 
from  the  renal  pelvis  may 
pass  without  halting,  and  sometimes  with  little  pain,  into  the 
bladder.  It  may  pass  after  repeated  attacks  of  renal  colic,  having 
remained  in  the  ureter  for  a  considerable  time.  It  may  be 
arrested  in  the  ureter,  and,  in  spite  of  repeated  attacks  of  colic, 
remain  impacted.     (Plate  23,  Figs.  1,  2.) 

The  calculus  becomes  arrested  in  the  ureter  on  account  of  its 
large  size,   irregular  shape,   or  rough  surface,   or  from  a  part  of 

319 


Fig.  80. — Two  articulating  ure- 
teral calculi  formed  on  fine  silk 
sutures  introduced  after  uretero- 
lithotomy. 


320 


THE  URETER 


[chap. 


the  ureter  being  too  narrow,  or  from  the  presence  of  a  fold  or  valve, 
or  of  a  stricture  caused  by  injury  from  the  previous  passage  of 
a  calculus,  or  from  laceration  or  rupture  of  the  ureter,  or  from 

the  pressure  of  a  tumour 
from  without. 

Position  of  impac- 
tion.— The  calculus  is 
usually  arrested  at  one 
of  the  three  narrow  parts 
of  the  ureter,  namely,  at 
the  outlet  of  the  renal 
pelvis,  at  the  brim  of 
the  bony  pelvis  (Figs. 
81,  82,  83,  84),  or  at  the 
entrance  of  the  ureter 
into  the  bladder  (Fig. 
86). 

Out  of  204  collected 
cases,  Jeanbrau  found 
the  calculus  in  the  lum- 
bar portion  of  the  ureter 
in  46  (22-8  per  cent.), 
in  the  iliac  portion  (just 
above  the  iliac  vessels) 
in  15  (7"4  per  cent.),  in 
the  pelvic  portion  in  105 
(52  per  cent.),  and  in 
the  intramural  portion 
in  36  (17-8  per  cent.). 

In  rare  cases  the 
position  of  the  calculus 
changes  with  the  posi- 
tion of  the  patient.  In 
a  patient  on  whom  I 
operated,  a  round  calcu- 
lus the  size  of  a  marble 
travelled  from  the  lower 
part  of  the  pelvic  ureter, 
in  which  position  it  was 
radiographed,  into  the 
lumbar  segment  of  the 
ureter  at  the  level  of  the 
iliac  crest,  on  the  patient 
being     placed     in     the 


Fig.  81. — Faceted  ureteral  calculi  re- 
moved from  ureter  at  brim  of  pelvis 
(upper  stone)  and  at  vesical  end  (lower 
stone).  Actual  size.  {See  Plate  23, 
Fig.  1.) 


Fig.  82.^ — Calculus  removed  from  pelvic 
portion  of  ureter.  Actual  size.  (See 
Plate  25,  Fig.  2.) 


XXII 1 J 


URETERAL    CALCULUS 


321 


Trendelenburg  position.     (Fig.  87.)     In  another  patient  two  stones 
threw   shadows,  one   at  the   pelvic   brim   and   the    other   at  the 
bladder,  and  were  found  in  this 
position  at  operation  ;  they  were 
faceted  and  articulated  with  each 
other.     (Fig.  8L) 

Number,  shape,  and  size 
of  calculi. — There  is  usually 
only  one  calculus  (90  per  cent.), 
but  there  may  be  two,  three, 
or  as  many  as  twenty-seven. 
The  calculi  are  bilateral  in  a 
small  number  of  cases  (3-6  per 
cent.). 

In  shape  they  resemble  a  date 
or  oHve-seed,  or  a  cofiee-bean, 
or  they  may  be  round,  or,  when 
large,  oval  or  sausage-shaped. 

The  surface  may  be  smooth 
and  polished,  or  granular,  or 
covered  with  small  basses,  or 
very  frequently  they  show  a 
spiculated  surface  of  sharp,  glis- 
tening crystals. 

Large  calculi  have  been  re- 
moved from  the  ureter.     Bloch 

removed  one  weighing  816  gr.,  Carless  one  weighing  803  gr.,  and 
Federoff  one  of  780  gr.  In  composition  they  resemble  renal  cal- 
culi. A  small  calculus  impacted  in  the  ureter  increases  in  size 
by   deposits   which   are  greatest  at   its  upper  end — that  nearest 


Fig.  83. — Calculus  removed  from 
ureter  at  brim  of  pelvis. 

Note  original  calculus  at  lower  end. 


Fig.  84. — Calculus  removed  Fig.  85. — Ureteral  cal- 

from    ureter    at    brim    of  cuius     removed     by 

pelvis  (actual    size)  previ-  operation, 
ous  to  formation  of  calculi 
shown  in  Fig.  80. 

the  kidney — and  the  nucleus  will  be  found  at  the  lower  or  vesical 
end  of  a  large  stone.     (Fig.  83.) 

The  wall  of  the  ureter  may  be  unchanged,  or  there  may  be  a 

V 


322 


THE  URETER 


[chap. 


stricture  below  the  stone,  or  a  diverticulum  in  which  the  stone 
lies.     In  old-standing  cases  the  ureter  above  the  calculus  is  dilated 


Fig.  86. — Ureteral  calculus. 

The  small  cone-like  end  projected  into  the 
bladder,  and  the  narrow  neck  was  grasped 
by  the  ureteric  orifice. 


Fig.  87. — Calculus  which 
travelled  up  a  dilated 
ureter. 


(Fig.  87)  and  the  walls  are  greatly  thickened,  so  that  the  duct 
is  the  size  of  the  small  intestine. 

When  the  stone  occupies  the  intramural  portion  of  the  ureter 


Fig.  88. — Types  of  ureteral  calculi. 

it  forms  a  rounded  swelling  in  the  bladder  to  the  outer  side  of 
the  ureteric  orifice,  and  it  may  project  into  the  bladder.  (Fig.  86, 
and  Plate  22,  Fig.  5.)    The  stone  may  ulcerate  through  this  part  of 


Fig.  89. — Oxalate-of-lime  calculi  passed  from  kidney. 

the  ureter  into  the  bladder,  leaving  a  ragged  opening  to  the  outer 
side  of  the  normal  orifice.     The  edges  of  this  eventually  become 


XX 1 1 1 


URETERAL    CALCULUS 


323 


smooth  and  rounded,  and  act  as  the  functional  ureteric  orifice. 
(Plate  22,  Fig.  7.)     Rarely  a  prolapse  of  the  ureter  is  caused. 
In  the  corresponding  kiduev  there  are  calculi  in  13  per  cent. 


Fig.  90. — Areas  of  fixed  pain  in  slowly  descending 
ureteral  calculus. 

The  uppermost  spot  represents  anterior  renal  pain  ;  the  lowest  spot,  pain   when  the  calculus 

had  reached  the  lower  end  of  the  ureter.     The  intervening  spots  were  pain  areas  at  intervals 

of  from  six  months  to  one  year. 

of  cases,  and  there  are  bilateral  renal  calculi  in  3  per  cent.  (Jean- 
brau).  Hydronephrosis  occurs  in  11  per  cent.,  pyelonephritis  and 
pyonephrosis  in  12  per  cent.  In  rare  cases  the  kidney  becomes 
sclerosed  and  atrophied. 


Fig.  91. — Position  of  pain  in  ureteral  calculus  at  brim 
of  pelvis,  marked  by  black  spot. 

The  scar  of  operation  for  extraperitoneal  removal  of  the  calculus  is  visible. 

Symptoms. — In  some  cases  of  ureteric  calculus  there  is  a  his- 
tory of  the  passage  of  a  calculus  at  some  previous  time.     When 


324 


THE  URETEK 


[chap. 


a  stone  descends  into  the  ureter  there  is  an  attack  of  renal  cohc, 
and  this  is  repeated  either  at  frequent  or  at  long  intervals.  The 
cohc  has  the  same  character  and  distribution  as  that  caused  by 


Fig.    92. — Pain-history  in  case  of  ureteral  calculus  which  became 
impacted  at  brim  of  pelvis. 

a,  b.  Severe  fixed  anterior  and  posterior  renal  pain,  August,  1901. 
c,  d,  Attacks  of  renal  colic,  October,  1901 . 

a  stone  in  the  renal  pelvis,  and  there  may  be  nothing  to  distin- 
guish the  two  conditions.  Frequently  the  cohc  commences  at 
some  spot  lower  than  the  Iddney,  and  shoots  downwards.     There 


XXIII]        PAIN    IN    URETERAL    CALCULUS 


325 


may  be  attacks  of  pain  which  does  not  radiate,  at  some  spot  in  the 
line  of  the  ureter.     (Figs.  90,  91,  92,  93.) 

Apart  from  tlie  attacks  of  colic,  there  may  he  fixed  pain  of  a 


Fig.  93. — Continuation  of  pain-history  (sir  Fig.  92). 

c,  Discomfort,  1901  to  1903.    /,  g.  Attacks  of  pain,  June,  1904.     /',  Fixed  pain,  July.  1904. 

dull  aching  character  over  some  part  of  the  line  of  the  ureter 
on  the  anterior  surface  of  the  abdomen.  Occasionally  there  is 
fixed  pain  in  the  back  just  above  the  crest  of  the  ilium  and 
outside  the   erector  spinae  mass  of  muscles.     The  fixed  pain  is 


326  THE   URETER  [chap. 

worse  on  inovcjiient  or  straiiiii)g,  and  is  increased  by  taking 
diuretics. 

The  attacks  of  colic  may  be  frequent  and  severe  until  the 
calculus  is  expelled  into. the  bladder.  The  patient  frequently  feels 
something  drop  into  the  bladder,  and  the  pain  ceases.  After  an 
interval  of  one  or  several  hours  or  of  a  few  days  the  calculus  is 
expelled,  either  easily  or  with  pain  and  strangury.  In  other 
cases,  after  a  period  of  frequent  attacks  of  renal  colic  the  attacks 
become  less  frequent  and  less  severe,  and  may  entirely  cease. 
During  the  attacks  of  colic  there  may  be  frequent  attempts  at 
micturition  and  very  little  urine  passed,  or  the  bladder  may  re- 
main undisturbed. 

When  the  stone  has  descended  to  a  point  just  outside  or 
within  the  wall  of  the  bladder,  certain  symptoms  are  often  super- 
added. Symptoms  of  bladder  irritation  become  prominent.  There 
is  frequent  micturition  day  and  night  with  strangury  and  pain 
referred  to  the  end  of  the  penis.  Genital  symptoms  also  appear. 
There  are'  painful  nocturnal  emissions,  pain  at  the  moment  of 
ejaculation,  hsemospermia,  and  intermittent  pain  in  the  correspond- 
ing testicle.  Genital  symptoms  are  explained  by  the  relations  of  the 
lower  end  of  the  ureter  to  the  seminal  vesicles  (Young).  There  is 
also  constant  pain  in  the  rectum,  aggravated  during  defaecation. 
These  symptoms,  however,  are  often  entirely  absent. 

Changes  in  the  urine  are  very  common.  Haematuria  may  be 
pronounced,  and  in  rare  instances  is  the  only  symptom.  It  usually 
follows  an  attack  of  renal  colic,  and  lasts  a  few  hours  or  one  or 
two  days,  and  is  aggravated  by  movement.  It  may,  however,  be 
absent  or  microscopic. 

During  an  attack  of  colic  there  may  be  temporary  diminution 
or  complete  suppression  of  urine.  Under  certain  circumstances 
anuria  becomes  established.  Sometimes  an  increased  quantity  of 
urine  is  passed  after  the  crisis  is  over,  or  the  quantity  may 
gradually  return  to  normal. 

In  rare  cases  there  may  be  continuous  polyuria.  In  a  man 
of  38  years,  with  a  small  calculus  in  the  pelvic  portion  of  the  left 
ureter,  the  quantity  of  urine  varied  from  120  to  165  oz.  in 
twenty-four  hours,  with  a  specific  gravity  of  1006.  After  uretero- 
lithotomy the  quantity  of  urine  fell  to  from  40  to  50  oz.  in  twenty- 
four  hours,  with  a  specific  gravity  of  1010  to  1024.     (Chart  16.) 

The  urine  may  contain  pus  and  bacteria,  crystals,  and  tube 
casts.  Phosphaturia  may  occasionally  be  present  without  other 
changes  in  the  urine. 

Course  and  progfnosis. — In  addition  to  calculous  anuria, 
which  is  a  rare  accident,  two  complications  occur,  both  of  which 


XXIII]  PALPATION    IN   URETERAL   CALCULUS  327 

are  alniosi.  iiicsilahlc  in  ait  irnpack'd  calculus;  tlicv  are  iufectiou 
and  chronic  urinary  ohsi ruction,  infection  is  usually  ha,'mato- 
genous  in  origin,  hut  may  he  introduced  hy  a  sound  or  catheter. 
Pyelonephritis  or  pyonephrosis  results.  Obstruction  takes  place 
insidiously,  and  may  not  cause  pronounced  symptoms  until  a 
large  hydrono])hrosis  is  found. 

Examination   of   the   patient.      1     Palpation. — There  may 
be  tenderness  on  palpation  at  some  part  of  the  abdomen  along 


JUNE 

JULY 

SEPTEMBER. 

DATE 

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12 

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16 

18 

20 

2 

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la 

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;/ 

Chart  16. — Polyuria  in  ureteral  calculus,  showing  drop  to 
normal  quantity  after  uretero-lithotomy. 

the  line  of  the  ureter.  If  this  is  due  to  a  stone  in  the  right 
ureter  at  the  level  of  the  brim  of  the  pelvis  the  tender  spot  is 
close  to  the  appendix,  and  may  lead  to  confusion. 

A  stone  is  seldom  of  sufficient  size  to  be  palpable  in  the  abdo- 
minal part  of  the  ureter. 

On  rectal  examination  in  the  male  a  stone  at  the  lower  end 
of  the  ureter  may  be  felt  above  and  outside  the  base  of  the 
prostate  as  a  small,  buried,  tender  nodule. 

A  large  stone  is  distinctly  felt  alongside  the  rectum.  In  a 
favourable  subject  I  have  felt  a  stone  as  high  as  the  brim  of  the 
pehas  on  rectal  examination.     In  the  female  subject  a  small  stone 


328  THE   URETER  [chap. 

can  usually  be  felt  in  the  lower  end  of  the  ureter  by  the  finger 
in  the  vagina. 

2.  Cystoscopy. — The  symptoms  may  be  similar  to  those  of 
vesical  calculus,  and  the  X-rays  throw  a  shadow  in  the  bladder 
area  when  the  stone  is  still  in  the  lower  end  of  the  ureter. 

By  cystoscopy  the  presence  of  a  calculus  in  the  bladder  is 
excluded. 

In  descending  calculi  the  ureteric  orifice  may  show  no  change 
even  where  the  stone  is  large  and  low  down.  More  frequently, 
however,  changes  are  observed :  the  ureteric  area  is  congested,  the 
lips  are  thick  and  the  orifice  is  gaping  (Plate  22,  Fig.  2).  There  may 
be  fine  ecchymoses  around  the  orifice,  or  a  flame-like  haemorrhage 
outside  the  opening  (Plate  22,  Fig.  3).  In  some  cases  one  or  both 
lips  are  bright-red  and  partly  evertfed.  When  the  stone  has  reached 
the  lower  end  of  the  ureter,  but  has  not  entered  the  intramural  part 
of  the  duct,  the  orifice  may  be  open  and  puckered  and  surrounded 
by  heaped-up,  dark,  velvety  mucous  membrane  (Plate  22,  Fig.  6), 
or  the  mucous  membrane  at  the  mouth  of  the  ureter  may  be 
converted  into  a  rosette  of  beautifully  transparent  cedematous 
bullse  or  into  delicate  transparent  clubs. 

Sometimes  the  oedema  spreads  to  the  base  of  the  bladder,  and 
large  cedematous  fingers  and  bosses  hide  the  trigone  from  view. 
In  other  cases  the  stone  has  reached  the  intramural  portion  of 
the  ureter,  and  appears  as  a  rounded  swelling  to  the  outer  side 
of  the  ureteric  orifice,  which  is  red  and  gaping. 

The  brown  or  white  tip  of  the  stone  may  project  from  the 
ureteric  orifice  (Plate  22,  Fig.  5).  Sometimes  it  is  crystalHne  and 
sparkles  in  the  cystoscopic  light. 

When  the  stone  has  passed  into  the  bladder  a  mushroom-shaped 
projection  of  mucous  membrane  may  prolapse  into  the  viscus 
(Plate  22,  Fig.  4)  like  a  prolapse  of  the  rectum,  or  the  orifice  is 
open  and  lacerated. 

The  efilux  when  a  calculus  is  descending  may  be  rapid  and 
forcible,  and  may  be  tinged  or  stained  with  blood  or  cloudy  with 
pus.  With  an  impacted  stone  low  down  in  the  ureter  the  move- 
ments at  the  orifice  are  frequently  slow  and  lazy,  and  the  efflux 
feebly  wells  out. 

3.  Sounding  the  ureter. — The  ureter  may  be  sounded  by  a 
ureteral  catheter  or  solid  ureteral  bougie  passed  by  means  of  a 
catheter  cystoscope.  The  bougie  may  be  arrested  by  the  calculus, 
or  it  may  hitch  and  then  pass  on.  Stenosis  of  the  ureter,  or  some- 
times a  fold  of  mucous  membrane,  or  angling  of  the  ureter  from 
a  loaded  rectum  or  a  poorly  filled  bladder,  may  block  the  passage 
of  the  catheter,  and  the  value  of  this  method,  if  used  alone,  is 


Fig.  1. — Prolapse  of  ureters.  The  partly  distended  prolapse  of  right 
ureter  and  a  small  part  of  prolapse  of  left  ureter  are 
seen.     (P.  315.) 

Fig.  2. — Right  ureteral  orifice  in  descending  ureteral  calculus  (in- 
fected). The  orifice  is  open  and  the  lips  are  rigid,  thick- 
ened, and  warped.     (P.  328.) 

Fig.  3. — Descending  ureteral  calculus  (non-infected).  Round  open 
left  ureteral  orifice  with  ecchymosis  near  edge.      (P.  328.) 

Fig.  4. — Eversion  of  ureteral  orifice  twenty  minutes  after  expulsion 
of  calculus  into  bladder.     (P.  328.) 

Fig.  5. — Uric-acid    calculus    partly    extruded    from    ureteral    orifice 

(P.  328.) 

Fig.  6. — Acute  ureteritis  in  descending  calculus.  Note  cedema  of 
ureteral  orifice  and  patch  of  ecchymosis.     (P.  328.) 

Fig.  7. — False  ureteral  orifice  produced  by  ulceration  of  calculus 
from  ureter  into  bladder.  True  ureteral  orifice  seen  on 
right.     (P.  323.) 


Plate  22. 


Plate  22. 


xxiii]  RADIOGRAPHY  IN  URETERAL  CALCULUS  329 

limited.  Kelly  has  used  wax-tipped  ureteric  bougies,  which  are 
passed  up  the  ureter  and  may  show  scratches  on  the  surface  of 
the  wax  if  a  calculus  is  present.  The  method  can  only  be  used 
in  the  female  and  with  a  Kelly's  tube,  as  the  bougies  do  not  pass 
freely  along  the  tunnel  of  the  catheter  cystoscope,  and  are 
scratched  by  the  rigid  orifice  of  the  instrument.  Newman  has 
introduced  a  fine  metal  sound,  which  is  attached  to  a  small  air 
balloon,  and  this  to  an  ear-piece.  The  contact  of  the  point  of  the 
sound  with  a  calculus  is  heard  by  the  operator.  The  application 
of  this  method  is  limited  to  female  patients,'  and  only  a  calculus 
in  the  lower  end  of  the  ureter  could  be  safely  reached  with  the 
metal  sound. 

Separation  of  the  urines  of  the  two  kidneys  by  the  separators 
or  by  the  ureteral  catheter  will  show  changes  such  as  blood,  pus, 
casts,  etc.,  on  the  diseased  side,  but  does  not  give  information  in 
regard  to  the  diagnosis  of  stone. 

4.  Radiography. — Radiography  is  the  most  accurate  and 
reliable  method  by  which  ureteric  calculus  is  diagnosed.  The 
radiographer  may  be  unable  to  show  very  small  calculi  or  those 
formed  entirely  of  uric  acid,  but  stones  the  size  of  a  split  pea  or 
even  less  can  be  demo^istrated.  Pure  uric-acid  calculi  mthout 
the  admixture  of  oxalates  or  phosphates  are  very  rare.  It  is 
necessary  that  the  whole  urinary  tract  should  be  examined  in 
every  case,  irrespectively  of  symptoms  localized  to  a  point  in 
one  ureter.  A  negative  should  always  be  obtained  and  examined  : 
•  the  screen  is  not  sufficient. 

A  ureteric  calculus  throws  a  shadow  in  the  line  of  the  ureter 
(Plate  23,  Figs.  1,  2,  and  Plate  25,  Figs.  2,  3).  This  hne  crosses 
several  bone  shadows — the  transverse  processes  of  the  3rd,  4th, 
and  5th  lumbar  vertebrae,  the  sacrum  internally  to  the  sacro-iUac 
synchondrosis,  the  spine  of  the  ischium,  and  frequently  the  hori- 
zontal ramus  of  the  pubes — and  in  a  doubtful  case  these  parts 
should  be  carefully  searched,  and,  if  necessary,  several  plates  taken 
at  slightly  different  angles,  as  well  as  stereoscopic  photographs.  In 
small  stones  the  shadow  is  usually  oval,  with  the  long  axis  in  the 
line  of  the  ureter,  and  they  are  generally  single.  Large  calculi 
form  round,  or  elongated  rod-like,  or  sausage-shaped  shadows. 

Shadows  thrown  by  other  conditions  may  lead  to  difficulty  in 
diagnosis  of  the  shadow.  Of  these  the  most  important  are  calci- 
fied lymph-glands  (Plate  24,  and  Plate  25,  Fig.  1),  appendices 
epiploicse,  atheromatous  patches  in  arteries,  phleboliths,  calcareous 
deposits  in  old  scars  or  chronic  inflammatory  tissue  or  on  hgatures 
from  a  previous  operation,  or  calcareous  deposits  in  the  seminal 
vesicles,  intestinal  contents  such  as  scybala,  foreign  bodies  in  the 


330  THE    URETER  [chap. 

bowel  (Blaud's  pills,  etc.),  fsecal  matter  coated  with  bismuth, 
calcuU  in  the  appendix,  and  enteroliths.  A  differential  diagnosis 
is  made  by  the  position  of  the  shadow,  the  shape,  the  numbers,  by 
stereoscopic  photographs,  and  by  the  clinical  history  {see  also  p.  305). 

Radiography  with  an  opaque  bougie  as  a  guide. — Although  a 
shadow,,  from  its  size,  shape,  and  density,  falls  within  the  sup- 
posed path  of  the  ureter,  some  further  method  of  diagnosis  will 
be  necessary  should  the  clinical  symptoms  not  clearly  point  to 
the  presence  of  a  calculus.  This  is  provided  by  the  passage  up 
the  ureter  of  a  bougie  opaque  to  the  X-rays.  These  instruments 
may  be  obtained  in  the  form  of  a  solid  bougie  or  a  catheter.  Lead 
and  antimony  are  metals  frequently  used  in  their  manufacture. 
The  method  of  introducing  an  opaque  bougie  into  the  ureter  and 
obtaining  a  radiogram  in  order  to  define  the  position  and  trace 
the  course  of  the  duct  was  first  used  in  the  living  subject  by 
Tuffier  (1897).  Tilden  Brown  published  observations  on  the 
method  in  1898,  but  it  was  first  placed  on  a  certain  and  practical 
basis  by  an  important  article  by  Kolischer  and  Schmidt  in  1901. 
In  1905,  Fen  wick  drew  attention  to  the  value  of  the  method  in 
ureteric  calculus.  The  bougie  may  be  arrested  by  the  stone,  and 
the  radiogram  shows  the  stone  shadow  at  the  tip  of  the  bougie 
shadow  ;  or  the  bougie  may  hitch  and  pass  on,  and  the  close 
relation  of  the  two  shadows  is  then  evident.  The  combination  of 
this  method  with  stereoscopic  radiograms  gives  very  accurate 
information;     (Plate  25,  Figs.  2,  3,  and  Plate  26.) 

Radiography  and  the  injection  of  collargol. — In  the  life-history, 
of  a  ureteral  calculus  there  comes  a  time  when  dilatation  of  the 
kidney  commences,  and  from  this  time  onwards  the  renal  tissue 
is  steadily  destroyed  by  expansion.  The  clinical  symptoms  give 
no  indication  as  to  when  expansion  is  commencing,  and  when  the 
kidney  is  found  large  and  hydronephrotic  the  renal  tissue  is  already 
destroyed.  By  the  passage  of  a  ureteric  catheter  and  the  injection 
of  collargol  (10  per  cent.)  a  shadow  of  the  contour  of  the  renal 
pelvis  is  obtained  and  early  dilatation  is  diagnosed  {see  p.  176). 

Treatment.  1.  Diuretic  treatment. — The  cases  suitable  for 
diuretic  treatment  are  those  of  small  stones  recently  engaged  in 
the  ureter  with  recurring  attacks  of  renal  colic,  and  especially 
where  a  calculus  has  previously  been  pased.  Potassium  citrate 
and  acetate  (15  or  20  gr.  thrice  daily),  theocin  sodium  acetate 
(3-8  gr.  twice  daily),  Contrexeville  (Pavilion),  Evian,  and  Vittel 
water,  are  some  of  the  diuretics  which  may  be  given.  Antispas- 
modics may  be  administered  at  the  same  time,  such  as  atropine 
and  belladonna.  A  visit  to  one  of  the  spas,  such  as  Contrexeville 
or  Vittel,  may  prove  successful  when  diuretic  treatment  at  home 


Fig.  1. — Two  calculi  in  right  ureter.  The  lower  round 
calculus  lies  just  outside  the  bladder,  the  upper 
long  oval  calculus  lies  obliquely  in  the  shadow 
thrown  by  the  sacrum  and  ilium,  and  was 
impacted  at  the  brim  of  the  pelvis,  lying  upon 
the  iliac  vessels.      (Pp.  319  and  320,  Fig.  81.) 

Fig.  2. — Oval  calculus  in  pelvic  segment  of  right 
ureter.     (P.  329.) 


Plate  23. 


Fig.   1. — Shadows  In  pelvis  due  to  calcareous  glands.     There  is  also 

a  calculus  In  left  ureter  (double  arrow).     (P.  329.) 
Fig.  2. — Shadows  thrown  by  calcareous  glands  in  region  of  pelvis  and 

ureter    on    right    side    (arrows).     Opaque    catheter    In    left 

ureter  (arrow).     (P.  329.) 
Fig.  3. — Shadow  thrown    by  calcareous   gland  (lower  arrow)  outside 

line    of   right    ureter.      Edge    of   psoas    muscle    shown    by 

upper  shadow.     (P.  329.) 


Plate  24. 


xxiii]    URKTFRAL  CALCULUS:    TREATMENT    331 

lias  failed.  The  I rcat^iuciit  should  he  liiuitt'd  to  four  or  six  luoiilJis, 
ut  the  (.'ud  of  wliicli  time  an  openilioii  sfiould  bo  rccoiniueiidcMl  if 
there  is  no  sign  of  the  stone  passing.  If  coUargol  examination  of 
the  renal  pelvis  and  calyces  shows  commencing  dilatation,  or 
bacteriological  examination  of  the  urine  shows  infection  to  have 
occurred,  iinniediate  o])erati()n  should  be  undertaken. 

2.  Instrumental  treatment. — The  passage  of  a  bougie  up  the 
ureter  is  sometimes  followed  by  the  expulsion  of  the  stone.  Oil 
has  been  injected  and  eucaine  introduced  along  a  ureteric  catheter 
to  assist  expulsion  and  relieve  spasm. 

Nitze  and  Jahr  have  passed  a  ureteric  catheter  with  a  mem- 
branous balloon  which,  when  distended,  dilated  the  ureter  below 
the  calculus. 

These  methods  are  only  successful  in  a  small  number  of  cases, 
and  safe  only  in  the  most  expert  hands. 

3.  Operative   treatment. — Operation  is  indicated — 

i.  In  calculous  anuria  {see  p.  278). 
ii.  When  medicinal  treatment  has  failed. 

iii.  When  infection  has  occurred. 

iv.  When  dilatation  of  the  kidney  is  commencing. 
When  the  calculus  .is  situated  in  the  lumbar  segment  of  the 
ureter  it  is  exposed  by  an  oblique  lumbar  incision  similar  to  that 
used  for  exposing  the  kidney,  and  the  ureter  found  at  the  lower 
end  of  the  kidney  and  traced  down  to  the  stone. 

When  the  stone  is  impacted  at  the  brim  of  the  pelvis  the 
ureter  is  exposed  by  a  curved  incision  commencing  at  the  level 
of  the  anterior  superior  iliac  spine  and  passing  downwards  and 
inwards  parallel  to  Poupart's  ligament  and  about  2  in.  above  it. 
The  incision  passes  through  the  abdominal  muscles,  care  being 
taken  at  the  inner  end  not  to  wound  the  veins  of  the  spermatic 
cord.  The  deep  epigastric  artery  is  ligatured.  The  transversalis 
fascia  is  carefully  divided  to  the  full  length  of  the  wound,  and 
the  patient  is  then  placed  in  the  Trendelenburg  position.  The 
peritoneum  is  now  reflected  along  the  external  iliac  vessels. 
The  ureter  adheres  to  the  peritoneum,  and  should  be  searched 
for  at  the  level  of  the  bifurcation  of  the  iliac  artery.  An  opaque 
line  or  a  leash  of  vessels  on  the  peritoneum  will  show  its  position 
if  the  stone  cannot  at  first  be  felt.  The  ureter  is  separated 
by  blunt  dissection  (Fig.  94),  but  should  not  be  extensively 
isolated  or  roughly  handled.  A  fine  catgut  suture  is  introduced 
before  removing  the  stone,  and  the  incision  in  the  ureter  should 
be  accurately  longitudinal.  The  ureteral  wound  is  closed  with 
fine  catgut  on  fine  rounded  needles.  The  abdominal  wound  is 
very  carefully  closed  with  stout  catgut  and  a  rubber  drainage 


332  THE   URETER  [chap. 

tube  introduced,  care  being  taken  to  keep  the  tube  high  up  to 
avoid  contact  with  the  iliac  vessels. 

Calculus  of  the  pelvic  portion  of  the  ureter  may  be  removed 
by  several  methods. 

By  an  extraperitoneal  route,  using  the  Trendelenburg  position 
and  the  same  curved  incision,  and  tracing  the  ureter  over  the 
brim  into  the  pelvis.     In  a  small  movable  calculus  the  ureter 


Fig.  94. — Operation  view  of  exposure  of  ureter  at  brim 
of  pelvis. 

The  ureter  is  being  detached  from  the  peritoneum  by  blunt  dissection. 

should  be  opened  above  the  iliac  vessels,  and  a  fine  scoop  (Fig.  95) 
or  long  ureteral  forceps  passed  down  and  the  calculus  removed. 
A  large  fixed  stone  must  be  removed  by  an  incision  through  the 
ureter  directly  over  it,  the  abdominal  muscles  being  strongly 
retracted  inwards,  and  a  good  light  being  directed  into  the 
wound  from  a  head-lamp. 


Fig.  1. — Shadows  thrown  by  calcareous  glands  below  and  internally 
to  left  kidney.     (P.  329.) 

Fig.  2. — Shadow  of  large  oval  calculus  in  pelvic  segment  of  left 
ureter,  and  opaque  bougie  lying  beside  it.  At  lower  end 
of  calculus  is  seen  denser  shadow  of  nucleus.  This  cal- 
culus produced  the  hydronephrosis  seen  in  Plate  4, 
Firf.     1.     (Pp.  329,  330.) 

Fig.  3. — Calculus  in^  pelvic  segment]  of  ureter  (arrow),  and  opaque 
bougie  lying  in  ureter.     (Pp.  329,  330.) 


Plate  25. 


Fig.  1. — Ureteral  calculus  lying  In  pelvic  segment, 
cystoscope  in  bladder,  and  opaque  bougie  in 
ureter.     (P.  330.) 

Fig.  2. — Two  calculi  lying  at  lower  end  of  right 
ureter  (arrows).  Cystoscope  is  seen  in 
position,  and  opaque  bougie  passed  into 
ureter  and  arrested  by  calculi.     (P.  330.) 


Plate  26. 


xxiii]  OPERATIONS  FOR  URETERAL  CALCULUS  333 

Other  inetliocls  of  exposing  the  ureter  are  described  in  the 
Chapter  on  Operations  on  the  Ureter  (Chap.  xxiv.).  For  stone 
in  the  pelvic  portion  of  the  ureter  the  sacral,  the  transperitoneal, 
the  vaginal,  or  the  transvesical  route  may  be  used. 

Calculus  in  the  intramural  portion  of  the  ureter  is  removed 
from  within  the  bladder  after  suprapubic  cystotomy.  The  bladder 
must  be  drained  by  a  tube  in  the  suprapubic  wound. 

After  all  operations  on  the  ureter  for  stone  the  duct  should 
be  examined  by  passing  a  bougie  downwards  into  the  bladder 
to  search  for  other  stones  or  for  stricture.  If  a  stricture  be 
present  it  should  be  incised  in  the  long  axis  of  the  duct,  and  if 
the  lumen  be  much  contracted  it  may  be  necessary  to  perform 
a  plastic  operation.  Dr.  R.  Dos  Santos  has  introduced  a  uretero- 
tonie  which  consists  of  a  concealed  knife  in  a  flexible  ureteric 
catheter.     This  is  of  use  in  cases  of  stricture  of  the  ureter. 

Apart  from  cases  of  calculous  anuria,  extraperitoneal  uretero- 
lithotomy has  an  operative  mortality  of  under  2  per  cent.  (1-66 


1^ 


Fig.  95. — Author's  pliable  scoop  for  ureteral  calculus. 

per  cent. — Jeanbrau).  When  other  operations  are  combined  with 
uretero-lithotomy  the  mortality  rises  to  13-11  per  cent.  Trans- 
peritoneal uretero-lithotomy  has  a  mortality  of  5-5  per  cent. 

Late  restdts. — Urinary  fistula  results  from  stenosis  of  the  duct, 
and  is  rare  (3  per  cent.).  Recurrence  is,  I  believe,  also  rare  {see 
p.  319).  Patients  on  whom  I  have  operated  have  remained  well 
seven  years,  five  years,  three  years  after  the  operation. 

In  the  early  stage  of  dilatation  of  the  kidney  the  organ  may 
completely  recover,  but  in  the  later  stage  recovery  of  the  renal 
tissue  is  only  partial. 

LITERATURE 

Bloch,  Folia  Urol.,  April,  1909. 

earless,  Proc.  Roy.  Soc.  Med.,  Jan.,  1910. 

Dos  Santos,  Med.   Contemp.,  Dec.  31,  1911. 

Fenwick,  Obscure  Diseases  of  the  Kidney.     1903. 

Jeanbrau,  Iks  Calculs  de  VUretere.     1909. 

Kelly,   Opcrdlirc   dyncEcology,  vol.  i.     1898. 

Kolischer  and  Schmidt,  Jonm.  Amrr.  Med.  Assoc,  Nov.  9,  1901. 

Morris,  Siiri/ical  Diseases  of  the  Kidney  and  Ureter.      1901. 

Rigby,   Ann.    Snnj.,   Nov.,    1907. 

Tuffier,  Traite  de  Chiriirrjie  (Duplay  et  Reclus),  1899,  vii.  418, 

Young,   Trnns.  Amer.  Assoc.  Gen.-  Urin.  Surg.,  1907,  vol.  ii. 


CHAPTER  XXIV 
OPERATIONS  ON  THE  URETER 

An  operation  upon  the  ureter  may  be  required  to  complete  some 
operation  upon  the  kidney  or  upon  the  bladder,  or  it  may  be  called 
for  to  remedy  some  injury  or  disease  of  the  duct  itself.  •  In  operat- 
ing upon  the  ureter  the  greatest  delicacy  and  gentleness  in  manipu- 
lation is  necessary.  The  muscular  wall  of  the  tube  is  easily 
torn,  the  blood  supply  readily  damaged.  The  penalty  of  rough 
handling  is  the  formation  of  stricture  and  fistula  of  the  ureter, 
and  the  ultimate  fate  of  the  kidney  is  often  nephrectomy. 

If  present,  sepsis  of  the  bladder  and  urethral  obstruction 
should  be  effectually  treated  before  the  operation  is  embarked 
upon.  In  some  cases  cystotomy  may  be  necessary  for  the  pur- 
pose of  drainage,  apart  from  any  question  of  intravesical  operation 
upon,  the  ureter. 

Renal  sepsis  usually  takes  the  form  of  pyonephrosis,  which 
should  be  treated  by  temporary  nephrostomy  before  the  plastic 
ureteral  operation.  When  the  infection  is  mild  this  may  not  be 
required,  but  in  such  cases,  and  even  when  no  infection  is  present, 
the  question  of  draining  the  kidney  as  a  temporary  measure  to 
spare  the  line  of  union  in  plastic  operations  on  the  ureter  should 
be  considered.  Extensive  stripping  of  the  ureter  is  to  be  avoided. 
The  adhesion  to  the  peritoneum  should  be  preserved  as  far  as 
is  compatible  with  the  freedom  required  for  a  plastic  or  other 
operation.  This  is  especially  important  when  the  duct  is  to  be 
or  has  been  cut  across,  and  the  continuity  of  the  anastomosis  of 
blood-vessels  severed.  The  ureter  can  be  cut  across,  or  it  may 
be  stripped  for  a  considerable  distance,  without  any  untoward 
result ;  but  if  it  is  both  cut  across  and  stripped,  sloughing  is  likely 
to  follow.  In  manipulating  the  ureter  delicate-toothed  forceps 
should  be  used,  and  care  taken  not  to  include  in  the  grip  the 
blood-vessels,  which  are  usually  quite  evident. 

Incisions  into  the  tube  should  be  made  longitudinally.  If  the 
tube  is  to  be  cut  across  it  is  usually  best  to  cut  it  obliquely,  so 
as  to  obtain  a  larger  Imnen,  although  this  is  not  necessary  in  a 
dilated  ureter. 

334 


ciiAi'.  XXIV]         EXPOSURE    OF    URETER  335 

The  finest  round-bodied  needles  should  be  used  if  the  ureter- 
is  of  normal  size.  A  cutting  needle  causes  a  considerable  amount 
of  damage  to  the  wall. 

Fine  soft  catgut  wliich  is  not  impregnated  with  strong  anti- 
septics such  as  iodine,  or  stiffened  with  chromic  acid,  should  be 
used  for  suturing.  Silk,  even  of  the  finest  size,  should  be  avoided, 
as  a  stone  will  form  on  the  suture  {see  p.  319).  It  is  seldom 
possible  to  suture  the  wall  without  including  mucous  membrane, 
nor  do  I  consider  that  this  matters  in  the  least  if  proper  catgut 
be  used.  Stitches  should  not  be  placed  too  near  together,  and 
should  not  bo  tied  too  tightly,  lest  the  line  of  suture  slough. 
Wherever  it  is  possible  some  covering  for  the  line  of  suture 
should  be  provided.  A  fold  of  peritoneum  or  a  tag  of  fatty 
tissue  is  invaluable  as  soldering  material  for  the  woimd.  A 
drain  should  be  placed  as  near  the  line  of  suture  as  possible, 
with  the  view  of  avoiding  accumulation  of  urine  should  leakage 
take  place. 

A  leak  during  the  first  two  or  three  days  does  not  mean 
failure  of  the  suture  line,  and  perfect  union  may  follow  if  no 
accumulation  of  urine  be  permitted. 

Exposure  of  the  Ureter 

The  ureter  may  be  exposed  by  a  transperitoneal  or  an  extra- 
peritoneal operation. 

The  four  regions  in  which  the  ureter  is  exposed  are  the  lumbar 
or  abdominal,  at  the  brim  of  the  bony  pelvis,  in  the  pelvis,  and 
in  the  wall  of  the  bladder. 

1.  Extraperitoneal  exposure  of  the  lumbar  segment  of 
the  ureter. — This  operation  is  generally  part  of  an  operation 
upon  the  kidney.  The  usual  oblique  kidney  incision  is  made  and 
the  lower  pole  of  the  kidney  exposed.  This  is  pushed  up  under 
the  ribs,  making  the  ureter  tense,  and  the  retroperitoneal  surface 
of  the  colon  is  displaced  forwards.  In  the  areolar  tissue  behind  or 
to  the  inner  side  of  the  colon  the  ureter  is  found  and  is  isolated 
by  blunt  dissection. 

By  carrying  the  lumbar  incision  forwards  just  above  the  anterior 
superior  iliac  spine  the  ureter  can  be  traced  as  far  as  the  brim 
of  the  pelvis  where  it  crosses  the  iliac  vessels. 

•2.  Extraperitoneal  exposure  of  the  whole  length  of  the 
ureter. — Extraperitoneal  exposure  of  the  ureter  commences  as 
an  oblique  lumbar  incision  at  the  angle  between  the  erector  spin* 
muscles  and  the  last  I'ib,  and  sweeps  roimd  the  anterior  supeiior 
iliac  spine  about  1  in.  above  and  internally  to  it.  The  incision 
then  runs  parallel  and  about  2  in.  above  Poupart's  ligament  to 


336  THE   URETER  [chap. 

the  outer  border  of  the  rectus  muscle  near  its  insertion.  In  this 
incision  the  epigastric  vessels  are  ligatured  and  cut. 

The  incision  has  been  used  for  ureterectomy,  especially  in 
tuberculous  disease  of  the  ureter.  It  is  not,  however,  necessary 
to  make  so  extensive  an  incision.  If  the  upper  wound  be  carried 
almost  to  the  anterior  superior  iliac  spine,  a  second  small  incision 
may  be  made  above  and  parallel  to  Poupart's  ligament  and  the 
pelvic  portion  of  the  ureter  treated  through  this. 

The  mutilation  of  the  abdominal  wall  is  much  less  by  this 
method,  and  a  more  satisfactory  scar  is  obtained. 

3.  Extraperitoneal  exposure  of  the  ureter  at  the  brim 
of  the  pelvis  and  in  its  pelvic  portion. — An  incision  about 
4  in.  in  length  is  made  1|  in.  above  and  parallel  to  Poupart's 
ligament,  commencing  a  little  internally  to  the  middle  of  that  liga- 
ment, and  curving  upwards  at  its  outer  extremity  to  pass  1  in. 
internallv  to  the  anterior  superior  iliac  spine. 

The  muscles  are  partly  cut  through  and  partly  split,  and  the 
transversahs  fascia  exposed.  This  is  incised  for  the  whole  length 
of  the  wound,  and  the  extraperitoneal  fat  and  peritoneum  are 
exposed.  In  the  male,  care  should  be  taken  at  the  inner  end  of 
the  incision  to  avoid  the  veins  of  the  spermatic  cord.  The  deep 
epigastric  vessels  usually  require  hgature.  After  exposure  of  the 
peritoneum  the  patient  is  placed  in  the  Trendelenburg  position 
and  the  peritoneum  raised.  The  external  ihac  vessels  are  followed 
and  the  ureter  searched  for  at  the  level  of  the  bifurcation  of  the 
common  iliac  vessels,  about  4  in.  from  the  surface  in  an  average 
body. 

The  ureter  hes  on  the  peritoneum  and  is  raised  up  with  it. 
If  it  be  normal  it  may  be  difficult  to  find.  A  faint  whitish  track 
on  the  peritoneum  or  a  fair-sized  blood-vessel  pursuing  a  long 
straight  course  may  be  the  only  guide.  (Fig.  94.)  The  spermatic 
or  ovarian  vessels  should  not  be  mistaken  for  those  around  the 
ureter.  The  normal  ureter  cannot  be  detected  on  palpating  the 
peritoneum.  Good  retraction  and  a  powerful  head-light  are 
important  aids  to  the  search.  When  the  ureter  is  dilated  it  is 
found  as  a  large  greyish  tube,  sometimes  the  size  of  the  small 
intestine,  with  a  tough  wall ;  but  even  when  it  is  of  considerable 
size  it  may  not  present  more  than  a  greyish  band  on  the  perito- 
neum until  a  few  strokes  of  the  dissecting  forceps  make  it  stand 
out.  I  have  had  great  difficulty  in  exposing  a  ureter  in  this 
position  in  a  case  where  there  had  been  chronic  appendicitis  with 
retroperitoneal  adhesions.  A  hard  tuberculous  ureter  or  a  ureter 
containing  a  stone  can  be  readily  detected  by  the  touch. 

Having  been  exposed  by  blunt  dissection,  the  ureter  may  be 


XXIV]  EXPOSURE   OF   URETER  337 

followed  over  the  brim  of  the  pelvis,  and  the  pelvic  portion  explored. 
The  portion  of  the  duct  below  the  pelvic  brim  alongside  the  rectum 
may  be  difficult  to  reach.  Beyond  this  the  ureter  passes  forwards 
and  is  more  easily  accessible  until  it  approaches  the  bladder,  when 
it  is  surrounded  by  numerous  vessels  and  in  the  female  runs 
below  the  uterine  artery. 

After  the  operation  a  rubber  drain  is  placed  in  the  iliac  fossa, 
and  great  care  should  be  taken  to  keep  it  from  touching  the  iliac 
vessels.  It  must  not  be  allowed  to  lie  over  the  brim  into  the 
pelvis,  for  it  will  certainly  press  upon  the  iUac  artery  and  cause 
sloughing  and  hsemorrhage  from  that  vessel.  Several  fatal  cases 
of  this  accident  are  on  record. 

If  the  ureter  has  been  opened  in  the  pelvic  segment  the  lower 
end  of  the  bed  should  be  raised,  so  that  any  leakage  of  urine 
may  pass  into  the  iliac  fossa  and  be  drained  by  the  tube.  I  have 
not  had  any  trouble  with  pelvic  cellulitis  even  in  septic  cases. 
Should  a  doubt  exist  in  the  case  of  a  female  patient,  a  small 
incision  should  be  made  through  the  vaginal  wall  and  a  tube 
placed  in  it  for  a  few  days. 

The  route  indicated  in  this  section  is  the  safest  and  most 
satisfactory  for  operation  upon  this  part  of  the  ureter. 

4.  Transperitoneal  exposure  of  the  ureter  at  the  brim 
of  the  pelvis  and  in  its  pelvic  segment. — A  median  incision 
is  made,  commencing  just  above  the  symphysis  pubis;  the  perito- 
neum is  opened,  the  patient  is  placed  in  the  Trendelenburg  position, 
and  the  intestines  are  packed  off. 

The  ureter  is  seen  appearing  just  internally  to  the  caecum, 
and  passes  over  the  brim  of  the  pehis,  crossing  the  bifurcation  of 
the  ihac  vessels.  It  can  be  traced  in  the  pelvis  imtil  it  disappears 
beneath  the  broad  ligament  in  the  female  and  the  seminal  vesicles 
in  the  male.  By  incising  the  peritoneum  over  it  the  duct  is  exposed 
in  any  part  of  the  pelvic  course. 

The  intraperitoneal  route  has  the  disadvantage  that  in  septic 
cases  there  is  a  grave  danger  of  infecting  the  peritoneum. 

0.  Parasacral  extraperitoneal  route  for  exposure  of  the 
pelvic  segment  of  the  ureter. — A  nimiber  of  operations  have 
been  described  by  Delbet,  Cabot,  and  others  for  the  exposure  of 
the  portion  of  the  ureter  by  a  sacral  route.  That  used  by  Morris 
will  be  described. 

A  straight  incision  5  in.  in  length  is  made  1  in.  from  and  parallel 
with  the  median  line,  commencing  2  in.  above  the  border  of  the 
gluteus  maximus  muscle,  and  extending  nearly  to  the  level  of 
the  anus.  The  edges  of  the  gluteus  maximus  and  great  sciatic 
ligament  are  divided,  the  rectum  and  vagina  are  pished  aside, 
w 


338  THE   URETER  [chap. 

and  the  ureter  is  found  as  it  crosses  the  tip  of  the  spine  of  the 
ischium. 

The  advantages  claimed  for  this  incision  are  the  absence  of 
bleeding,  the  avoidance  of  the  peritoneum,  and  the  dependent 
drainage.  Morris  advocates  it  especially  in  women.  The  dis- 
advantage is  the  narrow,  cramped  field  of  operation. 

6.  Vaginal  route. — An  incision  is  made  transversely  through 
the  upper  part  of  the  lateral  vaginal  wall.  The  ureter  is  exposed 
by  blunt  dissection  and  isolated,  care  being  taken  to  avoid  the 
uterine  artery,  which  crosses  above  and  close  to  it.  The  ureter  is 
incised,  the  stone  removed,  and  the  wound  closed  with  catgut 
sutures. 

The  vaginal  route  is  used  when  a  stone  can  be  felt  in  the  ureter 
and  the  exposure  of  the  duct  is  made  without  difficulty.  When 
the  duct  is  not  thickened  or  contains  a  stone,  it  may  be  very  diffi- 
cult to  find.  An  unduly  large  percentage  of  urinary  fistulae  have 
followed  this  operation,  due  probably  to  mistakes  in  technique. 

7.  Vesical  route  for  calculi  in  the  intramural  portion  of 
the  ureter. — Suprapubic  cystotomy  is  performed  and  the  patient 
placed  in  the  Trendelenburg  position.  The  edge  of  the  ureter  is 
seized  with  long  forceps,  the  mucous  membrane  slit  up  with  long 
curved  scissors,  and  the  stone  removed.  The  bladder  should  be 
drained  suprapubically,  and  not  closed,  as  there  is  a  danger  of 
ascending  pyelonephritis  even  in  a  mildly  infected  bladder. 

8.  Transvesical  route  for  calculi  lying  in  the  lower 
two  inches  of  the  ureter  outside  the  bladder  wall. — I  have 
performed  the  following  operation  where  great  difficulty  was 
experienced  in  exposing  the  lower  part  of  the  ureter  by  the  iliac 
extraperitoneal  route. 

After  suprapubic  cystotomy  the  patient  is  placed  in  the  Tren- 
delenburg position  and  the  wound  well  retracted.  A  curved 
incision  with  the  concavity  towards  the  trigone  is  made  Ih  in. 
outside  the  ureteric  orifice  on  the  affected  side.  A  flap  of  bladder 
wall  is  turned  down,  and  by  pulling  on  this  the  ureter  is  made 
tense  and  exposed.  It  is  surrounded  by  a  number  of  blood-vessels 
which  may  require  ligature.  After  removal  of  the  stone  the  duct 
is  stitched,  and  the  curved  wound  in  the  bladder  closed  with 
catgut  stitches  on  a  rubber  tube  which  drains  the  extravesical 
space  and  is  brought  out  of  the  cystotomy  and  suprapubic  wounds. 
The  bladder  is  also  drained. 

A  perineal  route  has  been  used,  but  this  and  the  rectal  route 
have  both  been  abandoned. 

Choice  of  route. — For  the  lumbar  segment  of  the  ureter  the 
lumbar  extraperitoneal  route  is  the  only  one  available.     To  expose 


XXIV]  URETERECTOMY  330 

the  ureter  at  the  brim  of  the  ))elvis  the  iUac  extraperitoneal  route 
is  the  })est,  and  this  route  is  also  the  most  satisfactory  for  the 
great  majority  of  cases  in  which  the  pelvic  portion  of  the  ureter 
is  to  be  exposed.  The  transperitoneal  route  may  be  useful  in 
some  cases  for  the  pelvic  segment  of  the  duct,  and  the  transvesical 
for  difficult  cases  of  impacted  stone  lying  just  outside  the  bladder. 
The  vaginal  route  is  also  a  useful  method  of  approach,  but  rough 
handling  should  be  avoided  and  the  ui-eter  carefully  stitched. 

Ureterectomy 

Partial  ureterectomy. — This  may  be  performed  as  part  of 
the  operation  of  nephro-ureterectomy.  The  kidney  with  a  part  of 
the  ureter  is  removed  for  tuberculous  or  other  disease  {see  p.  293). 

The  operation  may  in  rare  instances  be  required  for  the  treat- 
ment of  stricture  or  other  disease  of  the  ureter.  Here  a  portion 
of  the  ureter  is  resected,  and  the  ends  of  the  tube  are  united  by 
one  of  the  methods  of  anastomosis. 

Total  ureterectomy. — This  is  part  of  the  operation  of  nephro- 
ureterectomy  which  is  described  elsewhere.  It  is  performed  for 
tuberculosis  of  the  kidney  and  ureter,  suppuration  and  dilatation 
of  the  ureter,  and  new  growths. 

The  ureterectomy  may  be  carried  out  at  the  time  of  the  nephrec- 
tomy (primary  ureterectomy),  or  it  may  be  deferred  to  a  later  date 
(secondary  ureterectomy).  In  the  latter  case  the  upper  end  may 
have  been  fixed  in  the  lumbar  wound,  or  it  may  have  been  re- 
turned to  the  retroperitoneal  space. 

In  primary  ureterectomy,  after  the  renal  pedicle  has  been  tied, 
the  patient  is  turned  on  his  back  and  the  lumbar  wound  con- 
tinued forwards  so  as  to  form  the  iho-lumbo-iliac  incision  already 
described.  The  ureter,  with  the  kidney  attached,  is  stripped  from 
the  peritoneum  and  traced  into  the  pelvis.  It  may  be  difficult 
to  remove  the  last  two  inches  of  the  duct,  and  this  is  usually  liga- 
tured and  left,  no  harm  resulting.  The  surgeon  may,  however, 
persist  if  the  condition  of  the  patient  warrants  it.  The  patient 
is  placed  in  the  Trendelenburg  position,  and  the  ureter  traced  up 
to  the  wall  of  the  bladder  and  ligatured  there.  In  the  female 
subject  Kelly  has  employed  an  incision  in  the  vaginal  wall  to 
expose  and  remove  the  lower  end  of  the  ureter.  Separate  lumbar 
and  iliac  incisions  may  be  made  {see  p.  336). 

Plastic  Operations  on  the  Ureter 

1.  Anastomosis  of  ureter  and  kidney. — These  operations 
are  used  in  hydronephrosis,  where  the  seat  of  the  obstruction 
at  the  renal  pelvic  outlet  is  inaccessible  owing  to  adhesions  or 


340  THE  URETER  [chap. 

perinepHritic  fat,  or  where  the  obstruction  is  irremediable.  The 
operations  consist  in  lateral  anastomosis,  transplantation  of  the 
ureter  into  the  lowest  part  of  the  sac. 

Incision  of  valves  and  uretero-pyeloplasty  are  methods  of 
dealing  with  obstruction  at  the  outlet  of  the  renal  pelvis.  These 
operations  are  described  under  Hydronephrosis  (p.  182). 

2.  Uretero -ureteral  anastomosis. — This  operation  is  used 
when  the  ureter  has  been  torn  or  cut  across,  or  when  a  portion  of 
the  tube  has  sloughed  as  a  result  of  blows,  stabs,  injuries  during 
childbirth,  or  when  it  has  been  injured  during  pelvic  operations. 
Immediate  suture  should  be  performed.  If  a  portion  of  the 
tube  be  damaged  it  should  be  excised  before  commencing  the 
anastomosis. 

The  methods  of  performing  uretero-ureteral  anastomosis  are 
described  at  p.  180. 

3.  Anastomosis  between  ureter  and  bladder. — This  opera- 
tion is  performed  for  fistula  of  the  ureter  near  its  lower  end,  usually 
caused  by  injury  during  a  pelvic  operation  such  as  hysterectomy 
or  ovarian  operations  in  the  female,  and  removal  of  the  rectum 
by  the  abdomino-perineal  method  in  the  male.  It  is  also  neces- 
sary in  resections  of  portions  of  the  bladder  wall  for  maHgnant 
growth  when  the  operation  involves  the  lower  end  of  the  ureter. 
In  cases  of  fistula  following  extensive  pelvic  operations  the  relations 
of  the  pelvic  organs  are  usually  completely  changed,  and  there 
may  be  very  extensive  development  of  scar  tissue.  On  this  account 
the  transperitoneal  method  of  approach  is  preferred  to  the  extra- 
peritoneal route. 

r  <4  The  operation  is  facilitated  by  passing  a  catheter  up  the  vesical 
end  of  the  ureter  by  means  of  the  catheter  cystoscope.  The 
abdomen  is  opened,  the  patient  is  placed  in  the  Trendelenburg 
position,  and  the  intestines  are  packed  off.  The  ureter  is  defined 
at  the  brim  of  the  pelvis  and  traced  downwards  to  the  seat  of  the 
fistula  if  possible.  Should  there  appear  to  be  a  prospect  of  obtain- 
ing union  of  the  two  ends  of  the  severed  tube,  a  ureteral  anasto- 
mosis should  be  carried  out.  If  this  be  not  feasible,  the  upper 
end  of  the  ureter  should  be  dissected  free  for  as  far  as  is  neces- 
sary and  implanted  in  the  bladder. 

An  incision  is  made  in  the  bladder,  and  the  tube  pushed  through 
and  stitched  from  the  inside  of  the  bladder  to  the  mucous  mem- 
brane. A  second  set  of  sutures  is  introduced  between  the  outer 
surface  of  the  bladder  and  the  ureter,  and  the  first  inch  of  the 
ureter  buried  by  folding  the  bladder  wall  over  it  by  means  of  a 
row  of  Lembert's  sutures. 

All  traction  on  the  sutures  must  be  avoided,  and  Ricard  stitches 


XXIV]     PLASTIC   OPKRATIONS  ON   URKTKR         'Ml 

the  bliiddcr  to  tli(^  purietal  pcrit.oiicmii  on  llic  sidi^  of  tlio  aiiasto- 
luosis,  to  prevent  tension.  The  bladder  should  be  drained  supra- 
pubically  by  a  large  rubber  drain. 

There  are  many  variations  in  the  iin|)luntation  of  the  ureter, 
Ricard  turns  back  a  cuft"  of  ureter  after  splitting  the  tube,  and 
stitches  it.  A  portion  of  the  ureter  is  made  to  project  into  the 
bladder,  and  the  bladder  and  ureteral  wall  are  sutured  above 
this.  Payne  splits  the  ureter  to  form  two  flaps.  A  U -suture  is 
introduced  through  each  flap  and  carried  through  the  vesical  wall 
from  the  inside. 

Transvesical  operations  are  sometimes  used,  but  are  rarely 
successful.  In  a  case  in  which  the  abdomino-perineal  operation 
for  rectal  carcinoma  had  been  performed  by  another  surgeon  a 
urinary  fistula  followed,  arising  from  the  right  ureter  about  2  in. 
from  the  bladder.  After  opening  the  bladder  I  made  a  free  incision 
in  the  bladder  wall  near  the  right  ureteric  orifice,  and  stitched  a 
large  drainage  tube  through  this  at  the  lower  end  of  the  upper 
segment  of  the  severed  ureter,  in  the  hope  that  a  permanent 
fibrous  track  would  result  and  form  a  new  communication  between 
the  ureter  and  the  bladder.  For  a  few  weeks  this  worked  admir- 
ably, but  contraction  took  place,  and  eventually  nephrectomy 
became  necessary. 

The  operations  for  implantation  of  the  ureter  in  the  bladder 
in  resection  of  the  bladder  wall  will  be  described  in  connection 
with  malignant  growths  of  the  bladder  (p.  481). 

4.  Implantation  of  the  ureter  on  the  skin  (dermato- 
ureterotresis. — This  operation  is  chiefly  employed  where  the 
urine  must  be  diverted  in  cystectomy.  It  may  also  be  used 
when  a  ureter  is  injured  and  ureteral  anastomosis  is  impracticable 
in  a  case  where  the  second  kidney  is  absent  or  inadequate. 

The  ureter  is  exposed  in  the  loin  and  isolated.  It  is  cut  across, 
and  the  lower  end  tied  and  dropped  into  the  retroperitoneal  tissue. 
The  upper  end  is  brought  up  to  the  surface  of  the  skin,  care  being 
taken  not  to  kink  or  twist  it.  The  cut  end  is  split,  and  the  flaps 
are  stitched  to  the  skin  at  the  edge  of  the  wound,  supporting 
stitches  being  placed  at  the  level  of  the  subcutaneous  fascia. 
A  rubber  tube  is  placed  alongside  the  ureter  and  pierces  the 
abdominal  wall.  This  forms  a  weak  spot  in  the  wall  and 
obviates  the  strangulation  of  the  ureter  which  sometimes  takes 
place.  The  results  of  this  operation  are  rather  better  than  those 
of  implantation  of  the  ureter  into  the  intestine,  but  stenosis  of 
the  orifice  and  ascending  pyelonephritis  cause  a  very  high  late 
mortality.  An  apparatus  similar  to  that  worn  in  nephrostomy 
is  used. 


342  THE   URETER  [chap. 

5.  Implantation    of    the    ureter   in    the    intestine.  —  The 

operations  performed  for  extroversion  of  the  bladder  are  described 
elsewhere  (p.  398).  The  following  operations  are  suitable  for 
cases  of  ureteral  fistula,  as  a  preliminary  to  total  cystectomy,  or 
for  wounds  of  the  ureter :  The  ureter  may  be  implanted  into 
the  caecum,  the  pelvic  colon,  or  the  ascending  or  descending  colon. 
In  the  majority  of  cases  the  transperitoneal  method  is  used,  but 
in  a  few  cases  the  operation  may  be  performed  extraperitoneally. 
The  abdomen  is  opened  either  in  the  middle  line  or  over  the  por- 
tion of  bowel  in  which  it  is  proposed  to  implant  the  ureter.  The 
ureter  is  exposed  by  cutting  through  the  peritoneum  over  it,  and, 
the  peritoneum  being  protected  from  the  septic  urine,  is  cut  across 
and  the  lower  end  ligatured  and  cauterized.  The  upper  end  is 
cut  obliquely  if  it  be  of  normal  calibre.  The  extraperitoneal  aspect 
of  the  bowel  is  exposed  and  the  obliquely-cut  ureter  implanted 
into  it. 

This  may  be  done  by  a  double  layer  of  continuous  catgut 
sutures,  the  first  layer  uniting  one  half  of  the  outer  layer  of 
the  ureter  to  that  of  the  intestine,  and  the  next  the  whole 
circumference  of  the  mucous  lining,  and  then  the  second  half 
of  the  outer  layer  in  a  manner  similar  to  that  used  in  intestinal 
anastomosis.  A  third  row  of  sutures  may  be  inserted  for  ad- 
ditional  security. 

In  order  to  prevent  the  actual  contact  of  faecal  matter  with 
the  ureteric  orifice.  Fowler  has  introduced  the  following  method : 
The  peritoneum  is  split  and  the  ureter  dissected  up  and  divided. 
The  upper  end  is  displaced  towards  the  bowel  beneath  the  peri- 
toneum and  fixed  to  the  surface  of  its  wall  by  a  few  stitches.  A 
rectangular  flap  of  the  bowel  wall  is  now  raised,  and  the  mucous 
membrane  dissected  from  the  muscular  coat.  The  flap  of  mucous 
membrane  is  doubled  on  itself  and  stitched  so  that  a  fold  with 
a  mucous  covering  on  both  sides  is  formed.  Between  this  and 
the  rectangular  flap  of  the  muscular  wall  the  end  of  the  ureter  is 
placed  and  secured  in  position.  The  muscular  flap  is  now  replaced 
and  stitched. 

Uretero-appendicostomy,  —  In  a  case  of  very  extensive 
papilloma  of  the  bladder  which  recurred  after  four  operations  I 
made  an  anastomosis  between  the  right  ureter  and  the  appendix. 
An  incision  similar  to  that  for  appendicectomy  was  made,  and 
extended  for  4  in.  The  patient  was  placed  in  the  Trendelenburg 
position,  and  the  appendix  found  lying  close  to  the  dilated  ureter 
at  the  point  at  which  it  crossed  the  iliac  vessels.  The  peritoneum 
over  the  ureter  was  incised  and  the  duct  freed  for  2  in.  and  then 
cut   across   between   two   ligatures.     A  longitudinal   incision   was 


xxiv]  URETERO-APPENDICOSTOMY  343 

iiuulo  ill  the  uj)p('r  .scfjjinciit.  The  jippendix  was  cut  across  obliquely 
and  two  catgut  stitches  were  passed  tlirough  its  wall  and  up 
inside  the  ureter,  drawing  about  an  inch  of  appendix  into  its  lumen 
through  the  longitudinal  opening.  The  sutures  were  passed  through 
the  wall  of  the  ureter  from  within  outwards,  and  tied.  The  longi- 
tudinal incision  was  carefully  closed  around  the  appendix,  and 
sutures  united  the  serous  surface  to  the  surface  of  the  ureter.  A 
flap  of  fat  from  the  meso-appendix  was  stitched  over  the  line  of 
suture,  and  the  wound  in  the  peritoneum  closed. 

For  three  days  the  urine  passed  by  the  colon,   but  sloughing 
occurred,  and  the  patient  died  of  ascending  pyelonephritis. 


PART  III— THE  BLADDER 

CHAPTER  XXV 
SURGICAL  ANATOMY  AND  PHYSIOLOGY 

Surgical  anatomy. — The  adult  bladder  is  a  pelvic  organ  when 
it  is  empty  or  moderately  full ;  when  distended,  it  is  partly 
abdominal. 

The  physiological  capacity  of  the  bladder  is  from  8  to  10  oz., 
but  it  may  be  so  distended  as  to  contain  several  pints,  or  even 
quarts. 

There  are  an  anterior,  a  posterior  or  postero-superior,  and 
two  lateral  walls,  a  base,  and  an  apex. 

The  apex  is  the  highest,  conical  portion  of  the  bladder,  and 
to  this  is  attached  the  urachus. 

The  extent  of  the  base  is  indefinite.  It  is  frequently  looked 
upon  as  the  portion  of  the  lower  segment  of  the  bladder  which  is 
uncovered  by  peritoneum.  In  cystoscopy  the  term  is  used  to 
indicate  the  trigone  and  an  undefined  area  of  bladder  wall  around 
this.  The  lateral  walls  are  concave,  and  a  recessus  lateralis  on 
each  side  is  sometimes  described. 

The  internal  meatus  of  the  urethra  is  on  a  level  with  and 
about  2  cm.  behind  the  middle  of  the  symphysis  pubis.  This  is 
the  most  fixed  part  of  the  bladder. 

The  peritoneum  covers  the  postero-superior  wall,  and  descends 
to  cover  half  the  seminal  vesicles  within  1  cm.  of  the  prostate. 
On  each  side  it  covers  the  greater  part  of  the  lateral  wall. 
When  the  bladder  is  empty  the  peritoneum  passes  directly  from 
the  abdominal  wall  on  to  the  bladder ;  when  the  viscus  is  full 
the  postero-superior  wall  is  pushed  up  to  form  the  apex,  and  the 
peritoneum  dips  down  on  the  front  of  the  bladder  for  a  short 
distance. 

The  area  of  bladder  wall  uncovered  by  peritoneum  above  the 
level  of  the  symphysis  pubis  is  about  1  or  1|  in.  with  moderate 
distension  of  the  bladder  (10  to  12  oz.)  ;   frequently  it  is  less,  and 

344 


(HAi.  xxv|         RHLATIONS  OF  BLADDER  345 

with  the  l)hi(l(h'r  I'lilly  distciKh-d  the  pciitroncal  fold  may  lj<^  loiiiid 
as  low  as  the  iqiiK'L'  boi'der  of  tlie  syiiii)hysis  i)ut)is.  The  perito- 
neum is  loosely  attached  to  the  bladder  by  ai'eolar  tissue,  and  is 
readily  stripped  from  its  anterior  surface.  At  the  apex  around 
the  attachment  of  the  urachus  and  at  the  upper  part  of  the  pos- 
terior wall  it  sometimes  adheres  firmly ;  but  below  this  and  on 
the  lateral  walls  it  is  readily  detached.  In  front  of  the  bladder, 
behind  the  symphysis  pubis,  is  a  space  filled  with  aret^lar  tissue, 
the  space  of  Retzius. 

Relations  of  the  bladder. — The  moderately  distended  blad- 
der lies  behind  the  symphysis  pubis  and  pubic  bones,  and  above 
these  it  comes  in  contact  for  a  very  short  space  with  the  posterior 
surface  of  the  anterior  abdominal  wall. 

The  posterior  wall  in  the  male  is  covered  with  peritoneum, 
and  in  relation  to  this  are  coils  of  small  intestine.  The  lateral 
wall  is  in  relation  to  peritoneum  as  low  as  the  obliterated  hypo- 
gastric arteries,  and  below  this  it  comes  into  relation  with  the 
obturator  internus  muscle  covered  by  the  parietal  layer  of  pelvic 
fascia,  and  then  with  the  levator  ani  muscle  covered  by  the  visceral 
layer  of  pelvic  fascia. 

The  base  in  the  male  is  in  relation  to  the  prostate,  which  extends 
rather  more  than  half-way  from  the  urethra  to  the  base  of  the 
trigone,  and  passes  out  laterally  beyond  the  ureteric  orifices. 

Behind  this  the  ampulla  of  the  vas  deferens  is  in  relation  to 
the  bladder  wall  on  each  side,  and  then  to  the  peritoneum  of  the 
pouch  of  Douglas. 

The  base  of  the  female  bladder  is  in  relation  to  the  anterior 
vaginal  wall,  which  extends  backwards  for  more  than  an  inch 
behind  the  base  of  the  trigone.  The  trigone  is  firmly  adherent 
to  the  vaginal  wall,  but  above  this  the  vagina  and  bladder  are 
loosely  attached.  The  bladder  wall  then  comes  into  relation  to 
the  anterior  surface  of  the  uterus  almost  to  the  apex.  At  the 
apex  the  peritoneum  covers  it  for  a  short  distance  before  being 
reflected  on  to  the  uterus. 

"  In  the  new-born  child  the  orifice  of  the  urethra  is  about  the 
level  of  the  upper  border  of  the  pubic  symphysis.  In  front  of 
this  orifice  the  bladder  extends  forwards  and  slightly  upwards  in 
close  contact  with  the  pubis  until  it  reaches  the  anterior  abdominal 
wall,  against  which  it  lies  until  within  about  1  cm.  of  the  umbilicus  " 
(Symington).  The  anterior  surface  is  entirely  uncovered  by  peri- 
toneum, which  posteriorly  reaches  as  low  as  the  level  of  the  orifice 
of  the  urethra.  At  birth  the  organ  is  described  as  being  essentially 
an  abdominal  organ.  According  to  Symington,  however,  if  a  line 
be  drawn  from  the  promontory  of  the  sacrum  to  the  upper  edge 


346  THE   BLADDER  [chap. 

of  the  symphysis,  fully  one-half  of  the  bladder  will  be  found  below 
this  line,  or,  strictly  speaking,  within  the  cavity  of  the  true  pelvis. 
The  organ  is  pear-shaped ;  it  has  no  base  and  no  lateral  recesses. 
As  the  child  grows  older  the  bladder  dilates  and  sinks  into  the 
pelvis,  so  that  at  the  age  of  10  it  is  a  pelvic  organ  with  the  same 
relations  as  in  the  adult. 

The  bladder  wall  consists  of  three  coats — mucous,  muscular, 
and  serous. 

In  the  contracted  male  bladder  the  posterior  wall  is  thicker 
than  the  anterior.  There  are  an  outer  and  an  inner  longitudinal 
muscular  layer  and  a  middle  interlacing  layer.  In  the  lateral 
walls  the  longitudinal  muscle  is  less  developed  or  absent. 

The  trigone  is  a  separate  structure  from  the  rest  of  the  muscular 
wall  of  the  bladder.  From  the  internal  longitudinal  layer  of  one 
ureter  muscular  bundles  pass  to  join  those  from  the  other  ureter, 
and  these  form  a  muscular  ridge  called  the  interureteric  ridge  or 
bar  of  Mercier.  Other  strands  of  longitudinal  muscle  pass  from 
the  ureters  towards  the  urethra,  and  flow  over  the  posterior  edge 
of  this  orifice  to  join  the  internal  longitudinal  muscular  layer  of 
the  urethra.  These  form  the  sides  of  the  trigone.  In  the  centre 
of  the  triangular  space  the  muscle  bundles  interlace  irregularly. 

The  sphincter  of  the  bladder  is  formed  as  follows  :  Beneath 
the  surface  layer  of  the  trigone  is  a  thick  layer  of  non-striped 
muscle  lying  on  the  upper  surface  of  the  prostate.  This  is  con- 
tinuous with  the  circular  layer  of  bladder  muscle,  but  distinguished 
from  it  by  being  thicker  and  the  bundles  being  more  closely  set. 
As  this  layer  approaches  the  urethra  it  becomes  thicker  and  forms 
a  thick  wedge  behind  the  opening  of  the  internal  meatus.  Thence 
it  is  continued  as  a  thin  layer  of  circular  muscle  surrounding  the 
urethra.  Along  the  front  wall  of  the  prostatic  urethra  is  a  thick 
band  of  circular  muscle  similar  in  its  compact  arrangement  to  that 
lying  upon  the  base  of  the  gland,  and  extending  as  a  gradually 
thinning  layer  to  the  apex  of  the  prostate.  The  sphincter  of  the 
bladder  is  a  fan-shaped  muscle  the  posterior  part  of  which  is  formed 
by  the  deep  circular  layer  of  the  trigone  muscle,  while  the  anterior 
part  is  spread  out  along  the  anterior  surface  of  the  prostatic  urethra. 
The  mucous  membrane  consists  of  transitional  epithelium,  the 
superficial  cells  of  which  are  characteristic,  having  several  nuclei, 
and  protoplasm  which  stains  less  deeply  on  the  surface  than  on  the 
deeper  layer.  The  surface  is  smooth  and  rounded  ;  the  deep  aspect 
shows  prickles.     There  are  no  papillae. 

In  the  normal  submucous  tissue  there  are  round  cells  either 
diffusely  distributed  or  grouped  in  nodules,  and  it  is  unsettled 
whether  or  not  these  represent  lymphoid  tissue. 


xxv|  ARTr:RIES   OF   BLADDER  347 

Leiidorl'  describes  j^Haiulular  structures  around  the  urethral 
orifice  and  at  the  base.  These  are  solid  or  hollow  epithelial  down- 
growths  and  glands  consisting  of  froni  one  to  five  lacuna)  which 
open  into  a  single  excretory  duct.  In  the  body  of  the  bladder 
only  the  epithelial  ingrowtJis  are  found,  and  the  apex  is  free 
from  glandular  structures.  The  mucous  membrane  is  smooth  and 
delicate,  and  freely  movable  upon  the  underlying  muscular  layer 
over  the  whole  bladder  surface.  Over  the  trigone  it  is  coarser 
and  firmer,  and  is  adherent  to  the  underlying  structures. 

At  each  angle  of  the  trigone,  set  on  the  ureteric  ridge,  is  the 
opening  of  a  ureter,  which  appears  as  a  fine  pink  slit. 

In  the  mucous  membrane  at  the  apex  there  is  frequently  a 
trace  of  the  urachus  in  the  form  of  a  dimple. 

The  urethral  orifice  is  a  half-moon-shaped  slit,  concave  back- 
wards. The  shape  is  due  to  the  prominence  of  the  uvula  vesicae 
on  the  posterior  lip,  which  passes  down  into  the  postmontanal 
ridge  and  to  the  verumontanum. 

Arteries. — The  arterial  supply  is  derived  from  branches  of 
the  internal  iliac  arteries.  The  superior  vesical  and  middle  vesical 
are  derived  from  the  unobliterated  portion  of  the  hypogastric 
artery  ;  the  inferior  arises  from  the  anterior  division  of  the  internal 
iliac,  frequently  in  common  with  the  middle  hsemorrhoidal.  The 
superior  supplies  the  apex  and  upper  part  of  the  body  of  the 
bladder,  the  middle  supplies'  the  rest  of  the  body  and  base  of 
the  bladder,  and  the  inferior  supplies  the  trigone. 

The  branches  perforate  the  muscular  wall  and  form  a  sub- 
mucous plexus  from  which  proceed  fine  branches  that  penetrate 
the  mucosa. 

On  the  surface  of  the  mucous  membrane  fine  twigs  can  be  seen 
with  the  cystoscope.  They  penetrate  the  mucosa  at  irregular 
intervals  and  break  up  into  fine  branches.  There  is  no  regular 
arrangement  of  these  vessels,  and  they  vary  very  considerably  in 
numbers  in  healthy  individuals.  When  the  vessels  are  engorged 
from  some  pathological  cause  the  fine  branches  can  be  seen  to 
anastomose  with  each  other  and  with  branches  of  neighbouring 
vessels.  In  many  bladders  deep-blue  branching  vessels,  three  or 
four  times  the  breadth  of  the  surface  vessels,  are  seen  coursing 
deeply  in  the  mucous  membrane.  The  fine  surface  vessels  cross 
these.  One  of  these  large  vessels  may  be  seen  rising  to  the  sur- 
face and  splitting  into  two  or  more  fine  surface  vessels.  One  or 
two  vessels  emerge  from  the  ureteric  orifice  and  pass  outwards 
and  backwards,  breaking  up  into  fine  branches.  In  an  area 
the  size  of  a  threepenny-piece  around  the  ureteric  orifice  the 
circulation  is  intimatelv  connected  with  that   of  the  ureter.     In 


348  THE   BLADDER  •  [chap. 

health  there  is  no  indication  of  this,  but  in  many  diseases  of  the 
ureter  this  area  shows  a  halo  of  congestion.  The  vascular  supply 
of  the  trigone,  as  seen  with  the  cystoscope,  is  distinct  from  that 
of  the  rest  of  the  bladder.  The  vessels,  which  are  much  larger, 
run  for  the  most  part  in  a  fan  shape  from  the  urethra  backwards 
over  the  trigone  area,  overlapping  it  a  little  at  each  side  and  at 
the  base.  The  fine  twigs  on  the  surface  anastomose,  and  at  the 
angles  of  branching  there  are  frequently  small  dilatations. 

Veins. — The  vesical  veins  do  not  correspond  to  the  arteries. 
Numerous  veins  pass  downwards  on  the  surface  of  the  front  of  the 
bladder  (anterior  vesical  veins)  and  join  the  large  veins  which  pass 
backwards  on  each  side  at  the  base  of  the  prostate.  The  posterior 
vesical  veins  collect  the  blood  from  the  apex  and  peritoneal  sur- 
face of  the  bladder  by  a  vertical  trunk,  and  by  a  horizontal  trunk 
which  collects  the  blood  from  the  lateral  wall  and  communicates 
with  the  anterior  plexus.  These  veins  form  several  large  trunks 
which  communicate  with  the  hsemorrhoidal  plexus  and  open  by 
a  single  trunk  into  the  internal  iliac  vein.  The  veins  of  the  trigone 
pass  into  those  of  the  prostatic  urethra. 

Lymphatics  (Fig.  96). — No  lymphatics  have  been  described  in 
the  mucous  membrane.  In  the  submucous  tissue  there  is  a  net- 
work of  lymphatic  vessels  from  which  numerous  branches  pass 
into  the  muscular  coat  vertically  to  the  surface,  with  free  lateral 
anastomoses.  From  this  network  spring  large  trunks.  On  the 
posterior  surface  two  parallel  trunks  course  from  the  apex  to  the 
base  and  drain  the  lateral  walls.  The  basal  lymphatics  communi- 
cate with  those  of  the  prostate  and  seminal  vesicles  in  the  male, 
and  the  anterior  vaginal  wall  in  the  female.  On  the  anterior  face 
of  the  bladder  there  are  one  or  two  collecting  trunks  situated  on 
each  side  of  the  middle  line.  A  few  small  lymphatic  glands  are 
found  on  the  outer  surface  of  the  bladder. 

The  lymphatics  from  the  anterior  surface  pass  to  glands  along 
the  external  iliac,  those  of  the  upper  part  of  the  bladder  pass  to 
the  external  iliac  and  to  the  hypogastric  glands,  while  those  of  the 
lower  part  of  the  posterior  wall  pass  alongside  the  rectum  to  the 
sacral  ganglia  lying  at  the  bifurcation  of  the  aorta. 

Nerves. — From  the  3rd,  4th,  and  5th  lumbar  nerve  roots 
nervi  communicantes  pass  to  the  sympathetic  chain  and  run  with- 
out interruption  by  the  three  mesenteric  branches  to  the  inferior 
mesenteric  ganglion.  From  this  ganglion  the  two  hypogastric 
nerves  emerge,  forming  the  hypogastric  plexus,  and  pass  to  the 
wall  of  the  bladder.  A  second  set  of  nerves  originate  in  the  2nd 
and  3rd  sacral  nerves  (nervi  erigentes  or  sacral  nerves),  and  pass 
to  the  hypogastric  plexus,  where  they  are  interrupted  by  ganglia, 


xxv] 


PHYSIOLOGY   OF   BLADDER 


349 


from  which  they  pass  to  the  fundus,  anterior  part,  and  neck  of 
the  bladder. 

Physiology. — In  the  healthy  individual  the  urine  collects  in 
the  bladder  and  is  passed  four  or  five  times  during  the  day,  and 
not  at  all  at  night.  About  8  or  10  oz.  are  passed  at  each  act  of 
micturition. 

Zuckerkandl  and  Frankl-Hjochwart  have  shown  that  in  normal 
individuals  there  is  slight  desire  to  micturate  when  100-500  grm. 
of  fluid  are  introduced  into  the  bladder  and  the  pressure  varies 


Fig.  96. — Lymphatics  of  bladder. 

E.I.A.,  External  iliac  artery;  I.I. A.,  internal  iliac  arter>'  ;  O.N.,  obturator  nerve  ;  H.A.,  hypo- 
gastric artery  ;    U,  ureter  ;    B,  bladder ;    R,  rectum  ;    X,  apex  of  bladder  when  distended  ; 
1  to  6.  lymphatic  trunks. 


from  10  to  30  cm.  of  water.  When  400-700  grm.  are  introduced 
there  is  a  powerful  impulse  and  the  pressure  rises  to  from  13  to 
53  cm.   of  water. 

When  the  bladder  is  slowly  filled  the  intravesical  pressure  very 
gradually  rises,  apart  from  any  contraction  of  the  bladder,  giving 
a  pressure  of  from  3  to  4  cm.  In  the  living  subject  the  gradual 
rise  is  followed  by  a  rapid  increase  synchronous  ^nth  a  contraction 


350  THE   BLADDER  [chap. 

of  the  bladder.  The  urine  is  retained  in  the  V^ladder  partly  by 
mechanical  conditions  and  partly  by  the  tonic  contraction  of  the 
vesical  sphincter.  In  the  cadaver  fluid  does  not  escape  from  the 
bladder  when  in  the  recumbent  or  the  erect  posture,  and  a  con- 
siderable quantit}'  can  be  injected  into  the  bladder  through  the 
ureter  without  any  escape  from  the  urethra.  Some  amount  of 
force  is  required  to  separate  the  elastic  walls  of  the  urethra  at 
the  vesical  orifice. 

The  compressor  urethrae  forms  a  second  sphincter,  partly  volun- 
tary and  partly  involuntary.  After  suprapubic  prostatectomy  the 
vesical  sphincter  does  not  resume  its  f miction  in  50  per  cent,  of 
cases,  and  the  compressor  acts  as  the  sphincter. 

Micturition  is  performed  by  relaxation  of  the  sphincter  and 
contraction  of  the  detrusor  muscle.  Two  theories  are  advanced 
to  explain  the  initiation  of  the  act : 

1.  It  is  said  to  arise  in  gradually  increasing  waves  of  contrac- 
tion caused  by  distension.  This  can  be  demonstrated  by  artificially 
distending  the  bladder  \\^th  fluid.  When  the  distension  reaches  a 
certain  point  contraction  of  the  detrusor  takes  place. 

If  during  the  expulsion  of  the  fluid  through  the  urethra  fluid 
is  run  in  as  rapidly  through  a  suprapubic  wound  the  contraction 
is  not  prolonged,  but  the  detrusor  relaxes  after  a  regular  period  of 
contraction,  and  this  is  followed  by  an  interval  of  relaxation  and 
then  another  contraction. 

2.  When  the  bladder  is  distended  to  a  certain  degree,  contrac- 
tions of  the  wall  occur  which  force  a  few  drops  into  the  sensitive 
prostatic  urethra,  from  which  the  reflex  is  initiated.  The  reflex 
can  be  produced  artificially  by  injecting  a  few  drops  of  silver 
nitrate  solution  into  the  prostatic  urethra,  which  produces  intense 
desire  to  micturate.  The  injection  of  cocaine  into  the  prostatic 
urethra  may  cause  retention  of  urine  when  the  bladder  is  full>' 
distended.  On  the  other  hand,  I  have  shovai  that  the  prostatic 
urethra  is  removed  in  the  operation  of  suprapubic  prostatectomy 
and  the  act  of  micturition  is  unimpaired. 

The  act  of  micturition  consists  in  the  accumulation  of  urine, 
^\■ith  slow  rise  of  intravesical  pressure  to  15  cm.  of  water  (Starling), 
followed  by  rhythmical  contractions  of  the  bladder  increasing  in 
force.  Afferent  impulses  pass  to  the  spinal  centre,  and  eft'erent 
impulses  cause  contraction  of  the  bladder  with  rise  of  intra- 
vesical pressure  to  20  or  30  cm.  of  water,  when  the  sphincter  re- 
sistance and  adhesion  of  the  urethral  walls  are  overcome  and  the 
urine  is  discharged.  The  act  of  micturition  can  be  voluntarily 
initiated  by  relaxing  the  perineal  muscles,  and  perhaps  also  the 
sphincter  of  the  bladder,  and  contracting  the  abdominal  muscles. 


XXV]  PHYSIOLOGY   OF   BLADDER  351 

The  passage  of  the  urine  can  be  voluntarily  interrupted  hy 
contraction  of  the  voluntary  perineal  muscles,  and  perhaps  also 
of  the  sphincter  vesicae. 

There  is  a  centre  for  micturition  in  the  lumbar  spinal  cord 
which  in  the  adult  is  subject  to  control  from  the  cerebrum. 

Reflex  micturition  can  be  carried  on  when  the  cord  is  cut  across 
above  this  centre. 

Complete  destruction  of  the  lumbar  centre  is  followed  at  first 
by  retention  of  urine  and  overflow,  and  later  the  bladder  acts  re- 
flexly  and  is  continent.  The  reflex  centres  here  are  apparently  the 
inferior  mesenteric  and  hypogastric  plexuses  of  the  sympathetic. 

Finally,  some  power  of  causing  contraction  is  possessed  by  the 
scattered  nerve  ganglia  in  the  bladder  wall  itself.  When  the 
organ  is  completely  isolated  from  the  nervous  system,  stimulation 
will  produce  contraction  of  its  wall. 

LITERATURE 

Frankl-Hochwart  und  Zuckerkandl,  Die  Nervdsen  Erkrunkungcn  der  Blase.     1898. 
Goltz  und  Treusberg,  Pfliigers  Arch.,  vols,  viii.,  ix. 
Goltz  und  Ewald,  Pflugers  Arch.,  vol.  Ixiii. 

Jarjavay,  Recherches  Anatomique  sur  V  Uretere  de  V  Homme.     Paris,  1856. 
Kalischer,  Die  Urogenitalmuskulatur  des  Dammes.     Berlin,  1910. 
Lendorf,  Anatomie.     1901. 

MUller,  Deuts.  Zeits.  f.  N-ervenheilkunde,  1901,  S.  886. 
Rehflsch,   Virchows  Arch.,  Bd.  cl. 
Symington,  The  Anatomy  of  the  Child.     1887.    • 
Walker,  Thomson,  Journ.  Anat.  and  Phys.,  April,  1996,  vol.  xl. 
von  Zeissl,  Wien.  ined.  Bldtt.,  1902,  Nr.  10. 

Zuckerkandl,  E.,  Handbuch  der  Urolojie  (von  Frisch  und  0.  Zuckerkandl),  Bd.  i., 
1904. 


CHAPTER  XXVI 
EXAMINATION  OF  THE  BLADDER 

1.  Inspection. — When  the  bladder  becomes  greatly  distended 
it  forms  a  prominent  rounded  swelling  between  the  pubes  and 
the  umbilicus.  When  the  patient  is  standing  there  is  only  a 
general  prominence ;  when  he  is  lying  on  his  back  the  rounded 
swelling  appears.     (Fig.  97.) 

2.  Palpation. — ^With  the  patient  lying  on  his  back,  the  shoulders 
raised  and  the  knees  drawn  up,  the  surgeon  places  his  hand  flat 
upon  the  suprapubic  region.  The  distended  bladder  is  felt  as  a 
firm  rounded  swelling  rising  out  of  the  pelvis.  The  apex  can  be 
distinctly  felt.  Sometimes  a  large  diverticulum  can  be  recognized 
on  palpation,  especially  when  it  is  surrounded  by  inflammatory 
thickening.  The  distended  bladder  is  dull  on  percussion ;  pressure 
upon  it  usually  gives  a  heavy  aching  sensation  in  the  perineum 
or  at  the  end  of  the  penis. 

3.  Rectal  examination. — Examination  of  the  rectal  surface 
of  the  bladder  is  made  with  the  patient  in  the  knee-elbow  position 
on  a  couch,  or  in  the  lithotomy  position.  The  portion  of  the  male 
bladder  which  can  thus  be  examined  is  about  l^  in.,  commencing 
just  behind  the  interureteric  bar.  In  front  of  this  the  seminal 
vesicles  and  prostate  intervene  between  the  finger  and  the  blad- 
der base.  With  the  fingers  of  the  other  hand  above  the  pubes 
a  bimanual  examination  is  made. 

The  distended  bladder  fills  up  the  space  above  the  prostate 
and  bulges  downwards  so  as  almost  to  bury  the  gland.  This  may 
be  simulated  by  a  collection  of  pus  in  the  peritoneal  pouch  of 
Douglas.  Thickened  ridges  of  hypertrophied  bladder  muscle  can 
sometimes  be  felt.  The  thickening  of  an  advanced  infiltrating 
growth  at  the  base  of  the  bladder  can  be  felt  in  this  situation. 
Calculi  are  very  seldom  detected  by  this  method  of  examination, 
but  a  very  large  calculus  may  be  felt  on  bimanual  examination. 

The  lymphatics  of  the  bladder  base  pass  out  along  with  those 
of  the  prostate  at  the  upper  and  outer  angle  of  the  prostate.  A 
sling  containing  blood-vessels  and  lymphatics  can  be  felt  on  each 
side  in  this  position.     In  this  lie  the  first  lymph-glands  of  the 


CHAP.  XXVI]       EXAMINATION   OF   BLADDER 


353 


chain  which  passes  to  the  internal  iliac  vessels.     Enlargement  of 
these  glands  can  be  detected  on  rectal  palpation. 

4.  Vaginal  examination. — The  short  urethra  can  be  felt  in 
the  anterior  vaginal  wall,  extending  backwards  from  the  outlet  of 
the  vagina  for  Ih  in.,  when  it  expands  into  the  trigone. 

The  trigone  can  sometimes  be  detected  on  palpation  of  the 
anterior  vaginal  wall,  and  the  ureters  may  be  felt  passing  out- 
wards from  each  lateral  horn.  Behind  the  trigone  the  bladder 
base  can  be  palpated  in  the  anterior  fornix. 

5.  Examination  by  catheters  and  sounds. — The  passage  of 
a  catheter  is  required  to  withdraw  the  urine  in  atony  of  the  bladder 
or  obstruction  of  the  urethra.     It  may  be  necessary  in  order  to 


Fig.  97. — Distended  bladder. 


ascertain  the  presence  and  quantity  of  residual  urine  after  the 
patient  has  passed  all  he  can  voluntarily,  or  it  may  be  used  to 
obtain  a  specimen  of  urine  from  the  bladder  for  examination  so 
as  to  avoid  contamination  by  the  urethra  or  the  external  genital 
organs.  Occasionally  it  may  be  necessary  to  drain  the  bladder 
continuously  by  tying  the  catheter  in  position  in  the  urethra. 
Sometimes  on  passing  a  catheter  a  calculus  may  be  felt  in  the 
bladder,  or  the  filling  up  of  one  part  of  the  bladder  with  a  growth ; 
or  fragments  of  a  growth  may  be  caught  in  the  eye  of  the  catheter 
on  withdrawing  the  instrument. 

Catheters. — Three  varieties  of  catheter  are  in  use — the  metal 
catheter,  the  flexible  catheter,  and  the  rubber  catheter. 


354: 


THE  BLADDER 


[CAHP. 


Metal  catheters  have  a  curve  corresponding  to  that  of  the 
urethra,  a  blunt  conical  end,  and  two  small  metal  loops  at  the 
proximal  end  to  assist  in  fixing  the  instrument  in  the  urethra 
should  it  be  desired  to  drain  the  bladder  continuously.  A  "  pros- 
tatic "  catheter  has  a  large  curve  and  a  much  longer  beak. 

Flexible  catheters  have  a  basis  of  finely  woven  silk,  which  is 
coated  without  and  within  with  a  flexible  preparation.  They  may 
be  straight  and  taper  to  a  point  which  has  a  bulb  or  olive  tip,  or 
they  may  be  of  the  same  calibre  throughout  and  have  a  blunt 
rounded  end,  or  the  end  may  be  bent  upwards  (coude  catheter), 
or  there  may  be  a  double  bend  (bicoude  catheter).  (Fig.  98.)  The 
tip  of  the  catheter  beyond  the  eye  should  be  sohd.  The  proximal 
end  of  these  catheters  should  be  trumpet-shaped  so  as  to  admit 
the  nozzle  of  a  syringe  or  a  glass  nozzle.  There  should  be  no 
ornamental  bone  attachment. 


Fig.  98. — Silk-wove  catheters. 

From  above  downwards  :    Olivary,  coude,  and  bicoude  varieties. 

Gum-elastic  catheters  are  less  flexible  than  those  just  described, 
and  can  be  bent  into  the  required  shape  for  use.  They  have  a 
mandarin. 

Rubber  catheters  are  soft  and  very  supple.  The  tip  of  the 
catheter  beyond  the  eye  should  be  solid,  and  the  proximal  end 
should  be  trumpet-shaped. 

Cleansing  and  sterilization  of  catheters. — Metal  catheters 
are  boiled  before  use.  After  use  they  should  be  syringed  through 
with  antiseptic  fluid  or  attached  to  an  apparatus  which  is  fixed 
to  the  water-tap.  The  grease  is  removed  from  the  surface,  and 
the  instruments  are  boiled,  dried,  and  laid  aside. 

Well-made  -flexible  catheters  can  be  boiled  in  water.  Additions 
to  the  water  have  been  suggested,  such  as  chloride  of  soda  (40  per 
cent.)  and  ammonium  sulphate  (10-12  per  cent.),  with  the  view 
of  preserving  the  surface  of  the  catheter.  They  should  be  boiled 
from  two  to  five  minutes  and  then  carefully  placed  in  cold  sterile 
water,  or  l-in-80  carbolic,  or  l-in-4,000  biniodide  of  mercury,  or 
after  removal  from  the  sterilizer  they  may  be  placed  upon  a  dry 


xxvi] 


STERILIZATION   OF  CATHETERS 


355 


sterile  towel  and  allowed  to  cool.  They  must  not  be  grasped  with 
forceps  in  removing  them  from  the  sterilizer. 

A  convenient  form  of  sterilizer  is  that  introduced  by  Zucker- 
kandl  (Fig.  99).  Tiiis  compact  apparatus  is  portable  and  durable. 
Another  sterilizer  for  flexible  catheters  has  been  introduced  by 
Herring.  In  this  the  catheter  is  boiled  in  liquid  paraffin  in  a 
straight  tube,  which  is  then  detached  and  the  ends  closed,  so  that 
the  tube  acts  as  a  carrier. 

After  use,  flexible  catheters  should  be  washed  inside  and  out 
to  remove  grease,  blood-clot,  etc.,  then  boiled  for  two  minutes, 
and  carefully  dried  and  put  away  dry. 

It  is  better  to  leave  catheters  exposed  on  a  tray  until  they  are 
thoroughly  dry  than  to  store  them  at  once. 

Grlass  tubes  for  storing  and  carrying  catheters  should  be  open 


Fig.  99. — Zuckerkandl's  catheter  sterilizen 

at  both  ends,  to  facilitate  cleaning  and  drying.  Flexible  catheters 
should  be  wiped  with  a  little  oil  or  dusted  with  lycopodium 
powder  before  being  put  away. 

Formalin  vapour  is  employed  for  the  sterilization  of  flexible 
catheters,  and  is  especially  useful  when  a  large  number  of  instru- 
ments must  be  sterilized.  At  St.  Peter's  Hospital  a  large  oblong 
copper  box  is  used.  This  contains  perforated  trays  which  hold 
several  hundred  catheters.  On  the  floor  of  the  box  is  a  cup-shaped 
depression  in  which  fluid  formalin  is  placed.  The  box  is  closed 
and  a  lamp  burns  under  the  cup  until  the  formalin  has  evaporated. 
The  box  is  kept  closed  for  two  hours,  and  then  air,  filtered  through 
cotton-wool,  is  pumped  through  to  remove  the  irritating  fumes. 
Boxes  on  a  smaller  scale  can  be  obtained  for  formalin  sterilization. 
For  single  catheters,  a  glass-stoppered  tube,  within  which  is  a  box 
perforated  on  the  inside  and  containing  a  granular  preparation  of 
formalin,  may  be  used.     The  efficiency  .of  these  tubes  as  sterilizers 


356 


THE   BLADDER 


[chap. 


ig  very  doubtful,  and  moisture  tends  to  collect  on  the  catheter 
and  destroys  its  surface. 

Rubber  catheters  can  be  boiled,  and  should  be  stored  dry  after 
carefully  removing  any  oil  or  grease.  For  the  convenience  of 
patients  who  are  compelled  to  pass  a  catheter  upon  themselves, 
small  round  sterilizable  metal  boxes  with  a  receptacle  for  oil  or 
vaseline  are  constructed.     (Fig.  100.) 

Lubricants  should  be  sterile  and  non-irritating.  Liquid  paraffin, 
sterilized  olive  oil,  and  vaseline  are  the  best. 

Impregnation  with  powerful  antiseptics  should  be  avoided. 
Many  elegant  preparations  are  manufactured.  In  using  metal 
bougies,  especially  those  of  large  size,  vaseline  is  the  best 
lubricant.      The  following  formula  may   be  employed :     Cocainae 

hydrochloridi  5  gr.,  olei  eucalypti 
10  minims,  adrenalin  (1  in  1,000) 
20  minims,  olei  ricini  J  oz.,  olei 
olivee  |  oz. 

Method  of  passing  cath- 
eters.— The  passage  of  a  catheter 
must  be  regarded  as  an  opera- 
tion of  the  first  magnitude.  The 
danger  to  the  patient  of  infection 
introduced  by  the  catheter  is  as 
great  as  that  incurred  by  the 
infection  of  the  peritoneum  in 
an  abdominal  operation.  The 
disastrous  effects  may  not  have 
their  full  fruition  at  once,  but 
the  ultimate  result  is  none  the 
less  certain.  It  is  true  that  a  healthy  bladder  is  able  to  deal 
with  bacteria  introduced  in  large  numbers  by  a  dirty  catheter,  no 
harm  ensuing,  or  only  a  transient  cystitis ;  it  is  also  true  that  some 
patients  with  enlarged  prostate  use  no  antiseptic  precautions  and 
go  for  many  years  unscathed — most  rural  practitioners  are  able 
to  relate  such  a  case  from  experience  or  hearsay.  These  facts  give 
a  sense  of  false  security,  and  are  the  cause  of  many  surgical  dis- 
asters. In  the.  bladder  obstructed  by  an  enlarged  prostate,  or 
the  seat  of  tuberculosis  or  other  disease,  bacteria  find  a  ready  soil, 
and  the  prognosis  in  these  cases  becomes  immeasurably  graver  if 
sepsis  is  introduced. 

It  is  impossible  to  ascertain  the  remote  mortality  of  septic 
catheterization  ;  but  the  rate  is  very  high. 

Passage  of  a  metal  instrument. — The  patient  is  recumbent  in 
bed  or  on  a  couch,  with  the  abdomen  and  thighs  well  exposed  and 


Scale  z 


Fig.  100. — ^Sterilizable   catheter 
box. 


XXVI]  PASSAGE   OF  CATHETER  357 

sterilized  towels  placed  across  the  knees  and  thorax.  The  surgeon 
stands  on  his  left  side.  The  penis  is  washed  with  antiseptic  solu- 
tion and  the  meatus  carefully  cleansed.  An  instrument  is  selected 
and  well  lubricated.  The  penis  is  grasped  behind  the  glans  with 
the  forefinger  and  thumb  of  the  left  hand,  and  the  tip  of  the  in- 
strument inserted  into  the  meatus.  The  shaft  of  the  instrument 
lies  transversely  across  the  patient's  left  Scarpa's  triangle.  The 
handle  of  the  instrument  is  now  carried  gently  towards  the 
patient's  abdomen  and  onwards  to  the  middle  line  so  that 
the  point  drops  downwards  and  backwards.  (Fig.  101.)  During 
this  manoeuvre  the  left  forefinger  and  thumb  draw  the  penis 
on  to  the  instrument  like  a  glove.  The  handle  is  lightly  held 
between  the  right  forefinger  and  thumb  and  gently  raised,  and 
the  shghtest  hitch  receives  instant  attention.  (Fig.  102.1  As 
the  point  passes  down  the  bulbous  urethra  the  left  hand  leaves 
the  penis  and  the  fingers  are  used  to  support  the  perineum.  The 
point  passes  into  the  membranous  urethra  as  the  handle  becomes 
vertical  (Fig.  103)  and  swings  downwards,  and  the  left  forefinger 
and  thumb  replace  the  right  while  the  handle  is  gently  depressed 
between  the  thighs  and  pushed  onwards  (Fig.  104),  The  point 
of  the  instrument  should  move  freely  from  side  to  side  if  it  is 
in  the  bladder.  Instead  of  swinging  the  handle  of  the  catheter 
to  the  middle  line,  it  is  sometimes  easier  to  carry  it  in  the 
opposite  direction  so  that  it  crosses  the  middle  line  below  the 
scrotum,  and  then  to  carry  it  across  the  right  Scarpa's  triangle 
to  the  middle  line  of  the  abdomen,  gradually  raising  it  so  that 
the  point  drops  downwards  along  the  urethra. 

Passage  of  a  flexible  catheter. — In  passing  flexible  catheters  it 
must  be  remembered  that  the  surgeon  has  little  power  of  changing 
the  direction  of  the  point  of  the  instrument,  and  the  passage  of  a 
straight  instrument  into  the  membranous  urethra  depends  upon 
its  pliability.  The  penis  is  grasped  behind  the  glans  by  the 
thumb  and  forefinger  of  the  left  hand,  and  kept  on  the  stretch 
to  render  the  urethra  straight  and  obhterate  the  folds  in  its  walls. 
The  instrument  is  introduced  vertically,  and  lightly  held  by  the 
corresponding  digits  of  the  right  hand  and  pushed  carefully 
onwards  until  it  reaches  the  bladder,  which  is  recognized  by  the 
escape  of  urine. 

Sounding  the  bladder. — Six  ounces  of  sterile  fluid  are  intro- 
duced into  the  bladder  through  a  catheter.  The  instrument 
is  passed  in  vertically  until  the  beak  reaches  the  membranous 
urethra,  when  the  handle  is  slowly  lowered  in  the  middle  line 
until  it  drops  between  the  thighs,  and  then  pushed  onwards.  It 
may  assist  the  passage  of  the  instrument  to  raise  the  patient's 


358 


THE  BLADDER 


[chap. 


Fig.  101. — Passing  metal  instrument. 

Position  1 :  Beakiin  anterior  urethra,  shaft  lying  parallel  to  left  Poupart's  ligament. 


Fig.  102. — Passing  metal  instrument. 

Position  2:  Shaft  swung  to  middle  line,  beak  in  bulbous  uiethra. 


XXVI]  PASSING   METAL   INSTRUMENT 


359 


Fig.  103. — Passing  metal  instrument. 

Position  3  :  Shaft  vertical,  fingers  of  left  hand  on  perineum,  beak  engaged  in  membranous  urethra. 


^ 


I 


Fig.  104. — Passing  metal  instrument. 

Position  4  :  Shaft  depressed  between  thighs  by  left  hand,  beak  in  bladder,  right  hand  pressing 
on  pubes  to  relax  suspensory  ligament. 


360  THE   BLADDER  [chap. 

pelvis  on  a  sand  pillow.  The  sound  should  be  passed  as  far  as 
possible  in  the  middle  line,  and  the  handle,  held  lightly  in  the  right 
thumb  and  forefinger,  turned  on  one  side  and  again  upwards ;  and 
this  is  repeated,  gradually  drawing  the  instrument  out  until  it 
reaches  the  internal  urethral  orifice,  on  which  it  hitches.  It  is 
now  passed  in  again  in  the  middle  line,  and  the  other  side  of  the 
bladder  searched  in  the  same  way.  Finally,  the  beak  is  turned 
downwards  and  the  post-trigonal  or  post-prostatic  area  searched. 
In  manipulating  the  instrument  the  grating  or  click  of  a  stone  in 
the  urethra  or  projecting  from  the  prostate  may  be  felt. 

6.  Exploration. — Exploration  of  the  female  bladder  with  the 
finger  after  dilatation  of  the  urethra  is  an  unsatisfactory  method 
of  examination.  Only  the  terminal  phalanx  of  the  finger  can 
^e  introduced,  and  by  pushing  the  bladder  down  from  above 
the  pubes  with  the  other  hand  a  part  of  the  superior  wall  can 
be  palpated.  Permanent  incontinence  of  urine  has  frequently 
followed  this  procedure,  which  has  now  been  entirely  superseded 
by  cystoscopic  examination. 

It  is  sometimes  necessary,  when  the  bladder  has  become  filled 
with  blood  clot  and  cystoscopy  has  been  found  impossible,  to 
explore  the  bladder  by  a  cutting  operation.  In  growths  of  the 
bladder  information  is  also  gained  respecting  the  base  of  the 
growth  which  may  not  be  obtainable  by  cystoscopy.  In  such 
cases  the  bladder  should  be  opened  suprapubically  and  the 
patient  placed  in  the  Trendelenburg  position.  By  means  of  full 
exposure,  by  bladder  retractors  and  the  use  of  a  head-lamp,  the 
interior  of  the  bladder  can  be  thoroughly  searched.  The  perineal 
route  in  the  male  and  the  vaginal  route  in  the  female  are  unsatis- 
factory and  inadequate  methods  of  exploration. 

7.  Radiogfraphy. — For  the  radiographic  examination  of  the 
bladder,  as  of  the  kidneys  and  ureters,  it  is  necessary  to  employ 
a  fixed  position  which  can  be  repeated  with  mathematical  exact- 
,ness  at  a  future  examination.  Estimation  of  the  position  of  the 
pelvic  organs  depends  entirely  upon  the  relation  to  the  pelvis, 
a  bony  ring  tilted  at  an  angle.  Unless  some  means  of  obtaining 
'uniformity  be  employed  the  variation  in  different  individuals,  and 
in  the  same  individual  in  different  examinations,  will  be  very 
great  {see  pp.  37,  305).  In  the  radiographic  plate  the  brim  of 
the  bony  pelvis  should  be  shown. 

A  normal  bladder  and  prostate  sometimes  throw  a  shadow  in 
a  good  plate.  The  prostatic  shadow  lies  behind  the  pubic  sym- 
physis and  the  pubic  bones.  It  does  not  project  below  the 
symphysis,  but  may  rise  very  slightly  above  it.  The  lateral  extent 
of  the  prostatic  shadow  varies,   but  it  seldom  extends  laterally 


Fig.   1. — Shadow     thrown     by    partly     distended     healthy     bladder. 

(P.  361.) 
Fig.  2. — Shadow    of   greatly    distended     bladder    (uppermost    arrow) 

and  of  diverticulum  (middle  arrow)  ;  catheter  lying  in  urethra 

(lowest  arrow).     (P.  361.) 
Fig.  3. — Shadow  of  ureteral  calculus  in  middle  line  of  bladder.    (P.  361.) 

Plate  27. 


Fig.  1, — Shadow  of  phosphatic  calculus  In  bladder  pushed  to  right  of 
middle  line  by  large  growth  on  left  side  of  bladder.     (P.  361. ) 

Figs.  2,  3. — Calculus  in  bladder  which  has  moved  to  the  left  of 
middle  line  from  patient  lying  on  left  side.      (P.  361.) 

Plate  28. 


XXVI]  RADIOGRAPHY   OF  BLADDER  361 

beyond  the  middle  of  the  pubic  bones.  The  shape  of  the  shadow 
thrown  by  the  bladder  varies  according  to  its  distension.  The 
lower  border  of  the  shadow  nearly  corresponds  to  the  upper  margin 
of  the  pubic  portion  of  the  pelvic  girdle.  In  moderate  distension 
the  bladder  has  an  oval  shape  with  the  long  axis  placed  trans- 
versely. (Plate  27,  Fig.  1.)  In  full  distension  the  shadow  is  more 
rounded  and  extends  farther  back  towards  the  promontory  of  the 
sacrum.  The  lateral  limits  of  the  bladder  in  moderate  distension 
do  not  pass  beyond  a  vertical  line  drawn  through  the  middle  of 
the  obturator  foramen,  and  the  posterior  limit  rather  more  than 
half-way  to  the  promontory.  If  the  bladder  is  distended  with  air 
a  clear  area  appears  on  the  plate. 

Radiographic  examination  of  the  bladder  is  chiefly  useful  in 
stone  and  in  diverticula  of  the  bladder.  A  stone  shadow  in  the 
bladder  area  may  be  thrown  by  a  stone  in  the  bladder,  a  stone 
in  a  diverticulum  (Plate  29,  Fig.  2),  or  a  stone  in  the  lower 
ureter.  It  is  seldom  possible  by  a  radiographic  examination  alone 
to  distinguish  between  these  conditions.  In  Plate  27,  Fig.  3,  the 
round  shadow  in  the  middle  line  was  thrown  by  a  calculus  which 
the  cystoscope  showed  lay  in  the  lower  end  of  a  solitary  ureter 
opening  in  the  middle  of  the  distorted  trigone.  At  a  later  date  a 
radiogram  showed  the  shadow  in  the  middle  line,  and  after  water 
had  been  passed  another  radiogram  showed  that  the  shadow  had 
moved  considerably  to  the  left,  demonstrating  that  the  calculus 
was  free  in  the  bladder.     (Plate  28,  Figs.  2,  3.) 

In  another  case  (Plate  29,  Fig.  1)  the  shadow  appears  in  the 
bladder  area,  but  the  calculus  lay  in  a  large  diverticulum  that 
opened  into  the  bladder  by  an  aperture  which  would  admit  a 
lead  pencil.  In  a  third  case  a  large  shadow  lay  on  the  left  side 
of  the  bladder  area,  and  on  cystoscopy  there  was  a  stone  on  the 
left  and  a  papillomatous  growth  on  the  right  side  of  the  bladder. 
(Plate  28,  Fig.  1.) 

A  stone  shadow  constantly  found  in  one  position,  not  in  the 
middle  line,  on  several  examinations,  with  varying  distension  of 
the  bladder,  is  more  likely  to  be  thrown  by  a  stone  in  the  ureter 
or  in  a  diverticulum  than  in  the  bladder,  or  the  stone  may  be 
pushed  to  one  side  by  a  growth.  Even  when  the  shadow  lies  in 
the  middle  line  it  is  not  certain  that  the  stone  lies  within  the 
bladder,  as  the  cases  quoted  above  show. 

Diverticula  are  demonstrated  by  filling  the  bladder  with  an 
emulsion  of  oxychloride  of  bismuth.  The  catheter,  filled  with  the 
bismuth  emulsion,  should  be  left  in  the  urethra  during  the  radio- 
graphic examination  to  act  as  a  guide,  as  the  bladder  is  frequently 
distorted  in  these  cases.     (Plate  27,  Fig.  2,  and  Plate  29,  Fig.  3.) 


362  THE   BLADDER  [chap. 

8.  Cystoscopy. — There  are  two  methods  of  cystoscopy — (1) 
indirect,   (2)  direct. 

1.  Indirect  cystoscopy. — The  indirect  method  is  carried  out 
by  means  of  a  cystoscope  after  distension  of  the  bladder  with 
fluid. 

(a)  Simple  cystoscope. — The  simplest  form  of  cystoscope,  of 
which  Nitze's  was  the  original  model,  consists  of  a  telescope  and 
a  lighting  apparatus  combined. 

The  instrument  is  20  cm.  long  and  has  a  calibre  of  21  Charriere. 
At  the  distal  end  there  is  a  short  beak  formed  by  a  small  detach- 
able electric  lamp  which  may  have  a  metal  or  carbon  filament. 
The  shaft  of  the  instrument  consists  of  a  double  tube,  between 
the  layers  of  which  is  an  insulated  wire  carrying  the  current  and 
returned  along  the  body  of  the  instrument.  At  the  proximal  end 
is  a  double  slot  for  the  movable  attachment  which  carries  the 


Scale   3 
Fig.  105. — Author's  irrigation  cystoscope. 

current  and  on  which  is  the  switch.  The  ocular  apparatus  con- 
sists of  a  prism  window  and  a  mirror  that  reflects  the  image  along 
the  tube,  in  which  is  a  series  of  lenses.  The  proximal  end  is 
expanded,  and  on  to  this  may  be  screwed  an  eye-piece.  For  use 
in  children  a  small-calibre  (15  Fr.)  cystoscope  is  used.  The  current 
is  supplied  by  a  small  accumulator  or  a  dry  cell  giving  about 
4J  volts.     The  image  is  inverted. 

(6)  Irrigation  cystoscope. — In  the  irrigation  cystoscope  the  outer 
tube  acts  as  a  catheter  and  carries  the  lighting  apparatus.  At  the 
proximal  end  of  this  there  is  a  valve  to  prevent  the  fluid  escaping. 
The  telescope  is  separate,  and  is  pushed  along  the  lumen  of  the 
catheter.  In  the  author's  pattern  (Fig.  105)  the  outer  catheter 
and  lighting  tube  can  be  boiled.  At  the  proximal  end  of  this  is 
a  valve  which  acts  by  a  spring  placed  outside  the  lumen  and 
may  also  be  used  as  a  turncock.  The  telescope,  which  is  made 
by  Zeiss,  gives  an  erect  image.     The  advantages  of  an  irrigating 


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XXVI]  CYSTOSCOPY  363 

cystoscope  are  that  only  one  introduction  of  the  instrument  is 
necessary,  and  that  the  bladder  can  be  washed  repeatedly  by  with- 
drawing the  telescope  and  without  removing  the  outer  tube  from 
the  urethra. 

(c)  In  the  catheter  cystoscope  provision  is  made  for  catheterizing 
the  ureters.  In  the  simplest  form  a  tunnel  is  placed  on  the  upper 
surface  of  the  simple  cystoscope.  This  opens  just  short  of  the 
window,  and  at  the  end  is  provided  with  a  small  movable  gutter 
which  can  be  raised  by  turning  a  screw  at  the  proximal  end  of  the 
cystoscope  and  serves  to  project  the  point  of  the  ureteric  catheter 
away  from  the  line  of  the  cystoscope,  facilitating  its  introduction 
into  the  ureter.  Either  one  channel  or  two  are  provided,  for  single 
or  double  catheterization  of  the  ureters. 

The  more  recent  models  combine  the  catheterizing  and  irrigat- 
ing cystoscope,  and  a  very  useful  instrument  is  thus  obtained. 

Method  of  performing  indirect  cystoscopy. — The  cystoscope  is 
cleansed  with  ether  soap  and  carbolic  lotion,  or,  if  the  author's 
pattern  is  used,  it  is  boiled.  The  patient  either  lies  on  a  couch 
with  a  sand  pillow  beneath  the  hips,  or  sits  in  a  special  chair 
with  the  knees  and  hips  flexed  and  the  thighs  widely  apart.  The 
urethra  is  anaesthetized  •  by  instilling  15  minims  of  a  4  per  cent, 
solution  of  novocaine  into  the  prostatic  urethra  by  means  of  a 
Gruyon's  syringe,  or  by  a  combination  of  alypin  with  suprarenin 
— tablets  of  alypin  0-02  grm.  (|  gr.),  suprarenin  boric  2  minims 
of  solution  in  1,000. 

A  catheter,  or  the  catheter  portion  of  the  irrigation  cystoscope, 
is  lubricated  with  glycerine  and  introduced,  and  the  bladder  filled 
with  10  or  12  oz.  of  warm  boric  solution  or  sterile  water.  The 
"  telescope  "  is  now  introduced,  the  light  switched  on,  and  the 
window  turned  to  the  base  of  the  bladder.  Air  or  oxygen  has 
been  used  instead  of  water,  but  both  have  many  disadvantages. 

There  may  be  difficulty  in  obtaining  a  clear  medium  owing 
to  haemorrhage  from  the  bladder  or  the  prostate.  Careful  washing 
with  sterile  water  or  very  weak  nitrate  of  silver  solution  (1  in 
10,000)  will  usually  overcome  this.  In  persistent  bleeding  adrenalin 
may  be  used.  I  inject  J  drachm  of  quarter-strength  1 -in- 1.000 
solution  of  adrenalin,  and  leave  it  in  for  a  half  to  one  minute,  and 
then  wash  it  out.  If  the  urine  be  purulent,  prolonged  washing 
may  be  necessary  before  a  clear  medium  is  obtained.  Spasm  of 
the  bladder  may  prevent  a  full  distension  ;  this  may  be  due  to 
using  cold  solution  or  injecting  it  too  rapidly,  or  to  cystitis.  If 
it  be  due  to  cystitis,  local  anaesthesia  may  be  obtained  by  washing 
the  bladder  with  a  5  per  cent,  solution  of  antipyrin.  A  general 
anaesthetic  may  be  necessary. 


364 


THE  BLADDER 


[chap. 


2.  Direct  cystoscopy  (the  open  method). — This  method  was 
perfected  by  Kelly,,  and  has  been  modified  by  Luys  and  others. 

Kelly's  specula  (Fig.  106)  are  plated  metal  cyHnders,  3J  in. 
long,  and  of  the  same  diameter  throughout.  There  is  a  funnelr 
shaped  expansion  at  the  outer  end  of  the  speculum,  and  a  handle 
3  in.  long  is  attached  to  the  funnel.  The  specula  are  made  in 
various  sizes,  from  5  to  20,  each  number  representing  the  diameter 
in  millimetres.  Each  instrument  has  an  obturator,  which  is  used 
during  introduction.  A  dilator  is  used  to  enlarge  the  orifice  of 
the  urethra  (Fig.  107),  and  an  evacuator  to  remove  the  urine 
which  accumulates  in  the  bladder  during  a  prolonged  examina- 
tion.    It  consists  of  a  rubber  exhausting  bulb  and  14  in.  of  fine 


Fig.  106. 
Kelly's  speculum. 


Fig.  107. 
Kelly's  dilator. 

rubber  tubing,  and  at  the  bladder  end  a  small  hollow  perforated 
metal  ball. 

The  lower  bowel  is  emptied,  and  immediately  before  the  exam- 
ination the  bladder  is  emptied  in  a  sitting  or  standing  position. 
General  anaesthesia  is  necessary  in  nervous  individuals.  Local 
anaesthesia  is  obtained  by  cocaine  introduced  on  pledgets  of  wool. 

Two  positions  are  used — (a)  the  elevated  dorsal,  (6)  the  knee- 
chest,  (a)  The  dorsal  position  is  the  less  trying  to  the  patient,  but  it 
is  only  of  service  in  thin  patients,  and  the  atmospheric  expansion 
of  the  bladder  is  not  so  good.  The  bladder  of  stout  patients  will 
rarely  distend  at  all  in  this  position.  The  buttocks  are  raised 
8  or  12  in.  above  the  table  level,  the  speculum  is  introduced,  the 
obturator  is  withdrawn,  and  the  atmospheric  pressure  distends 
the  bladder.  (6)  In  the  knee-chest  position  the  patient  kneels, 
with  the  knees  slightly  separated,  close  to  the  end  of  the  table, 
and  lets  the  back  curve  in  with  the  buttocks  well  xaised. 


XXVI]  CYSTOSCOPY  365 

If  an  anaesthetic  is  required  the  patient  may  be  held  by  assist- 
ants, or  a  slinging  apparatus  may  be  used. 

The  speculum  is  introduced,  the  obturator  withdrawn,  and 
light  projected  through  it  from  a  forehead  mirror  reflecting  lamp, 
or  from  an  electric  lamp  held  over  the  sacrum.  After  an  examina- 
tion the  bladder  is  emptied  by  introducing  a  catheter  and  gently 
lowering  the  patient  to  the  horizontal. 

Kelly's  method  is  only  applicable  to  the  female,  and  the  posi- 
tion is  an  exhausting  and  embarrassing  one. 

Luys  has  modified  this  method,  and  uses  it  in  the  male  also. 
His  instrument  consists  of  a  metal  tube  of  10  cm.  for  the  female 
and  18  cm.  for  the  male.  On  the  floor  of  the  tube  is  a  fine  tunnel 
leading  to  a  small  tube  to  which  a  rubber  tube  and  aspirator  bottle 
are  attached,  and  which  prevents  the  accumulation  of  urine  in 
the  bladder.  The  plunger  that  closes  the  tube  during  introduction 
is  straight  in  the  instrument  for  the  female,  and  angled  in  that 
for  the  male. 

The  patient  is  placed  in  the  Trendelenburg  position,  with  local 
or,  preferably,  general  anaesthesia. 

It  is  not  always  possible  to  obtain  complete  distension  of  the 
bladder,  and  there  are  folds  and  depressions  in  the  mucous  mem- 
brane. An  area  at  the  apex,  the  anterior  and  part  of  the  lateral 
walls,  are  inaccessible  to  examination. 

As  a  method  of  examination,  direct  cystoscopy  is  inferior  to 
indirect.  With  the  tube  a  small  area  of  the  bladder  wall  is  seen, 
and  the  instrument  must  approach  it  closely  in  order  to  get  a  good 
view.  With  the  indirect  cystoscope  an  extensive  field  is  displayed 
and  a  broad  bird's-eye  view  can  be  obtained.  The  advantage  of 
the  direct  or  open  method  is  the  facility  it  presents  for  topical 
applications  in  cystitis,  for  operations  on  small  papillomas,  and 
for  the  removal  of  foreign  bodies  from  the  bladder. 

Cystoscopic  appearance  of  the  normal  bladder. — When 
the  cystoscope  is  introduced  the  beak  is  turned  downwards  and 
the  trigone  comes  into  view.  This  is  examined,  and  the  inter- 
ureteric  bar  at  the  base  of  the  trigone  recognized  and  followed 
out  on  either  side,  and  the  ureteric  orifices  noted.  Then  the 
posterior  wall  and  the  lateral  walls,  and  finally  the  anterior  wall 
and  the  apex,  are  examined. 

A  portion  of  the  posterior  wall  near  the  apex  is  difficult  to  see, 
and  the  ocular  end  of  the  instrument  must  be  fully  depressed  so 
as  to  tilt  the  window  upwards  and  bring  it  into  view.  The  ante- 
rior wall  rises  almost  vertically  from  the  urethral  orifice,  and  the 
window  of  the  cystoscope  looks  along  it. 

The  mucous  membrane  is  smooth  and  sandy-yellow,   and    it 


366  THE   BLADDER  [chap,  xxvi 

reflects  the  light  so  that  the  whole  viscus  is  easily  illuminated. 
Fine  vascular  twigs  appear  here  and  there,  and  branch  freely. 
Their  number  varies  greatly  in  different  healthy  individuals. 
Larger  vessels  of  a  blue  colour  are  usually  seen  here  and  there 
shining  through  from  the  deeper  layers  of  the  mucosa.  The 
mucous  membrane  of  the  trigone  is  coarser  and  darker  in  hue. 
The  vessels  are  larger,  and  pass  in  a  fan-shaped  arrangement  from 
the  urethral  orifice,  overlapping  the  sides  and  the  base  of  the 
trigone. 

The  ureteric  orifices  are  seen  as  fine  pink  slits  on  the  ridge 
at  the  base  of  the  trigone,  and  are  found  by  following  this  ridge 
(the  bar  of  Mercier)  outwards  on  either  side.  One  or  two  small 
blood-vessels  emerge  from  the  ureteric  orifice  and  pass  outwards 
and  backwards.  At  the  apex  of  the  bladder  there  is  usually  a 
small  bubble  of  air  which  has  been  introduced  during  the  washing 
of  the  bladder. 

The  urethral  orifice  is  seen  by  withdrawing  the  window  until 
it  is  partly  in  the  prostatic  urethra.  It  has  a  slightly  concave, 
even  contour  all  round. 


CHAPTER  XXVII 

METHODS    OF    COLLECTING    THE    URINE    AND 
EXAMINING  THE  FUNCTION  OF  EACH  KIDNEY 

At  the  present  time  two  methods  are  available  for  collecting  the 
urine  of  each  kidney  separately : 
L  The  use  of  separators. 
2.  Catheterization  of  the  ureters. 

L  Intravesical  separation  of  the  urines. — Two  models 
of  separator  are  in  use,  those  of  Luys  and  Cathelin. 

Lulls'  separator  (Fig.  108)  consists  of  a  shank  and  a  handle. 
The  shank  has  a  central  metal  stem,  mth  a  metal  catheter  fitted 
on  each  side.  The  distal  end  of  the  shank  is  curved  to  the  extent 
of  about  half  a  circle,  the  curve  lying  below  the  straight  portion 
of  the  shank.  Attached  to  the  end  of  the  central  flattened  stem 
is  a  fine  chain,  which,  when  loose,  lies  snugly  in  the  concavity  of 
the  curve.  When  drawn  tight  by  a  screw  in  the  handle  this  chain 
bridges  across  the  half-circle  curve  like  the  string  of  a  bow.  A 
fine  rubber  tube  fits  over  the  whole  of  the  median  stem.  With  the 
chain  slack  the  rubber-covered  central  stem  retains  its  pecuhar 
curve  ;  with  the  chain  taut  the  half-circle  curve  is  filled  in  by  a 
rubber  membrane,  forming  a  septum  which  divides  the  bladder 
in  two  parts.  The  metal  catheters  fit  on  each  side  of  the  central 
stem,  and  open  one  on  each  side  of  the  membrane  at  the  depth 
of  the  curve.  At  the  handle  of  the  instrument  they  curve  out- 
wards as  fine  tubes  over  two  movable  glass  receptacles. 

In  Cathelin' s  separator  the  shaft  is  straight  with  a  small  curved 
beak.  Concealed  within  the  shaft  is  a  membrane  stretched  on  a 
spring  hasp.  When  the  membrane  is  projected  by  pushing  in  the 
shank  the  spring  frame  expands  and  a  membranous  di\asion  is 
formed.  On  each  side  small  catheters  project  and  drain  each 
compartment  of  the  bladder  thus  produced. 

IVIethod  of  using  separators. — The  instrumeiit  is  prepared 
by  adjusting  the  membrane  and  lubricating  it.  The  patient  lies 
on  the  back  on  an  operating  chair.  The  bladder  is  washed  until 
the  fluid  returned  into  a  glass  vessel  is  clear.     From  6-8  oz.  of 

367 


368 


THE  BLADDER 


[chap. 


fluid  are  allowed  to  remain  in  the  bladder.  A  1  per  cent,  solution 
of  cocaine  hydrochlorate,  15  or  20  minims,  is  injected  into  the 
urethra.  In  the  female  the  instrument  is  readily  passed  into 
the  bladder ;  in  the  male  the  Luys  separator  passes  easily  until  the 


Fig.  108. — Luys'  separator. 

A,  Shank  and  handle  ;  the  rubber  membrane  has  been  drawn  over  the  curve  and  shank,  conceal- 
ing the  chain  in  the  concavity  of  the  curve.     B,  B,  Metal  catheters.     C,  Cap  to  unite  shank  with 
catheters.     D,  Component  parts  adjusted  ready  for  introduction.     E,  Curve  of  instrument  with 
chain  drawn  taut  and  separating  membrane  expanded. 

curve  lies  in  the  prostatic  urethra.  The  handle  is  now  depressed 
deeply  between  the  thighs  and  pushed  gently  onwards.  The 
patient  is  gently  raised  into  a  sitting  posture,  and  the  instrument 
is  drawn  towards  the  surgeon  and  held  in  the  median  line  of  the 


xxviij       CATHETERIZATION   OF  URETERS 


309 


body  with  a  slight  upward  inclination.  The  screw  is  now  turned 
and  the  chain  rendered  taut,  forniing  the  membranous  septum 
in  the  bladder.  A  rectal  or  vaginal  examination  is  made,  to  ensure 
that  the  instrument  is  in  position.  The  first  fluid  is  discarded, 
the  tubes  are  placed  in  position,  and  the  examination  is  continued 


Fig.   109. — Author's  catheterizing  cystoscope. 


for  twenty-five  minutes.  In  the  case  of  Cathelin's  instrument  the 
introduction  is  easier,  and  the  instrument  is  pulled  towards  the 
operator  until  the  beak  fits  against  the  pubes.  The  membranous 
septum  is  then  projected. 

2.  Catheterization  of  the  ureters. — Many  catheter  cysto- 
scopes  are  in  use.  Those  of  Nitze,  Casper,  Albarran,  Freudenberg, 
Ringleb,  and  Israel  are  well  known  and  reliable.  The  instruments 
have  already  been  described.  My  pattern  (Fig.  109)  has  the  same 
valve  as  my  irrigation  cystoscope.  Ureteral  catheters  are  30  in. 
long,  and  are  of  different  sizes,  varying  from  No.  5  to  No.  8 
Charriere.     The  end  may  be  blunt  or  conical,  or  may  have  a  fine 


Fig.  110.^ — -Author's  ureteral  catheters. 

olivary  bulb.  There  are  two  lateral  eyes,  or  the  eye  may  be 
terminal.  Albarran's  catheter  has  a  slightly  thicker  part  proximal 
to  the  second  eye,  to  prevent  the  escape  of  urine  alongside  the 
catheter.  My  own  catheters  (Fig.  110)  are  graduated  in  divisions 
of  black  and  brown  of  |  in.  each,  and  a  narrow  red  band  marks 
each  6   in.     The   end  is   blunt   or   olivary,  the   eyes    are  lateral. 

Y 


370  THE   BLADDER  [chap. 

There  is  a  slight  thickening  proximal  to  the  second  eye.  The 
proximal  end  is  obliquely  cut,  but  is  not  trumpet-shaped,  as  it 
must  pass  through  the  tunnel  of  the  cystoscope. 

The  catheters  are  sterilized  by  cleaning  them  with  biniodide 
of  mercury  solution  (1  in  1,000)  and  thoroughly  syringing  with 
the  same  solution  before  and  after  use  with  a  special  fine  nozzle 
syringe  which  fits  the  catheter  (Fig.  111).  Before  laying  the 
catheter  aside  it  is  rubbed  with  a  trace  of  sterile  oil,  and  a  little 
oil  is  injected  through  it  to  prevent  cracking.  The  catheters 
should  be  kept  in  enamelled  tin  trays  or  in  long  glass  tubes  open 
at  both  ends. 

A  general  anaesthetic  is  unnecessary  unless  in  the  case  of  a  con- 
tracted tender  bladder,  such  as  may  be  met  with  in  tuberculous 
disease.  Local  ansesthesia  and  the  preparation  of  the  bladder  are 
the  same  as  for  cystoscopy.  The  amount  of  distension  of  the 
bladder  for  catheterization  of  the  ureters  is  the  same.  It  is  some- 
times necessary  in  an  irritable  contracted  bladder  to  catheterize 


s  sg. 


L  LM'     _    AKiJJl  Y 

c 


Fig.  111. — Author's  syringe  for  washing  out  ureteral 
catheters. 

the  ureters  with  a  small  quantity  of  fluid  in  the  bladder.  I  have 
occasionally  had  to  be  content  with  between  2  and  3  oz.  of  fluid. 

The  cystoscope  should  be  loaded  with  a  catheter  before  it  is 
introduced,  but  the  point  of  the  catheter  must  not  project  from 
the  tunnel.  On  the  bladder  being  reached,  the  beak  is  turned 
downwards,  the  light  switched  on,  and  the  interureteric  bar  comes 
into  view.  This  is  followed  outwards  on  one  or  the  other  side 
by  rotating  the  instrument,  when  the  slit-like  opening  of  the 
ureter  comes  into  view.  The  ocular  end  of  the  instrument  is 
now  carried  towards  the  opposite  thigh,  and  the  window  and 
catheter  opening  travels  towards  the  ureteric  orifice.     (Fig.  112.) 

The  catheter  is  projected  so  that  the  point  lies  about  the 
middle  of  the  field  of  vision.  The  catheter  is  then  manoeuvred 
as  close  to  the  orifice  as  possible,  and  finally  the  elevating  gutter 
raised  by  a  touch  of  the  screw,  the  point  of  the  catheter  sinking 
between  the  lips  of  the  opening  and  being  slowly  and  gently 
pushed  on.  (Fig.  113.)  When  the  catheter  has  passed  a  few  inches 
up  the  ureter  the  elevator  is  lowered,  and  the  catheter  glides 
more  easily.     The  catheter  should  be  passed  into  the  renal  pelvis. 


xxvii]       CATHETERIZATION   OF   URETERS  371 

which  is  reached  when  the  double  red  band  indicating  12  in.  hes 
at  the  ureteric  orifice.  If  it  is  intended  to  catheterize  both  ureters 
and  a  double-barrelled  cystoscope  is  being  used,  the  second 
catheter  is  now  introduced  ;  or  if  a  single-barrelled  cystoscope  is 
being  used,  this  is  withdrawn — leaving  the  first  catheter  in  posi- 
tion— reloaded,  and  introduced,  and  the  second  ureter  catheter- 
ized.  Each  catheter  is  fixed  with  a  piece  of  adhesive  plaster  to 
the  thigh  of  the  side  to  which  it  belongs,  and  it  drains  into  a 
sterilized  bottle  labelled  "  right  "  or  "  left." 

By  Kelly's  open  method  the  ureteric  catheters  are  introduced 
direct  through  the  large  tube. 

The  ureter  may  also  be  sounded  by  passing  a  catheter  to  ascer- 
tain if  any  obstruction  exists ;  or  a  solid  opaque  bougie  may  be 


Fig.   112. — ^Gatheter  approach-  Fig.   113. — Catheter  lying  in 

ing  ureteric  orifice.  ureter. 

passed  up  the  .  ureter  in  order  to  differentiate  by  means  of  the 
X-rays  between  stone  in  the  ureter  and  extra-ureteral  shadows. 

Kelly  has  suggested  the  passage  of  a  bougie  tipped  with  wax 
which  will  receive  scratches  apparent  to  the  naked  eye  from  the 
rough  surface  of  a  calculus.  This  method  cannot  be  used  with 
the  indirect  method  of  catheterization  of  the  ureters,  as  the  wax 
would  be  scratched  in  the  tunnel  of  the  cystoscope. 

Difficulties,  such  as  temporary  cessation  of  function  of  the 
kidney  due  to  the  catheterization,  blocking  of  the  catheter  with 
blood  clot,  thick  pus,  or  even  gravel,  inaccessibility  of  the  ureter, 
smallness  of  the  ureteric  orifice,  or  enlarged  or  tuberculous  pros- 
tate, may  be  met  with,  but  are  less  formidable  as  greater  expe- 
rience is  gained.  With  proper  precautions  there  is  no  danger  of 
infecting  the  ureter  and  kidney. 


372  THE   BLADDER  [chap. 

Choice  of    an   instrument  for  separation  of    the  urines. 

1.  Ease  of  application. — The  separator  is  more  easily  introduced 
than  the  ureteral  catheter.  It  is  imperative,  however,  to  make  a 
cystoscopic  examination  before  using  the  separator,  so  as  to  ascer- 
tain that  the  bladder  is  healthy. 

2.  Danger  of  infecting  the  kidneys. — In  proper  hands  there  is 
no  danger  of  infection  of  the  renal  pelvis  and  kidney  by  a  catheter. 

3.  Accuracy  of  separation. — The  ureteral  catheter  is  more 
accurate  than  the  separator  in  obtaining  the  uncontaminated 
urine  from  one  kidney.  The  results  of  the  examination  are  so 
important  that  the  surgeon  cannot  accept  any  report  on  which 
a  doubt  can  be  cast. 

4.  Duration  of  the  examination. — The  separation  can  only  be 
borne  for  twenty  minutes  or  half  an  hour,  and  cannot,  therefore, 
be  used  for  the  majority  of  the  tests  for  the  renal  function.  The 
ureteric  catheter  can  be  left  in  position  for  four  or  five  hours 
without  discomfort. 

Catheterization  of  the  ureters  is  the  method  which  has  been 
most  widely  adopted.  Its  accuracy  is  greater  and  its  sphere  of 
usefulness  far  wider  than  that  of  the  separator,  which  it  has  now 
entirely  superseded. 

Examination  of  the  urine  of  each  kidney. — In  cases 
of  slight  pyuria  or  hsematuria,,  where  the  bladder  is  healthy  and 
there  is  no  indication  as  to  which  side  is  aiiected,  it  is  often 
impossible  to  detect  a  slight  cloudiness  of  the  efflux  with  the 
cystoscope.  Examination  of  the  urine  drawn  by  catheter  from 
each  kidney  will  localize  the  disease  in  these  cases.  In  disease 
of  one  kidney,  when  nephrectomy  is  proposed,  the  presence  of 
a  second  kidney  and  its  health  and  functional  power  are  ascer- 
tained by  the  same  method. 

In  examining  the  urines  of  the  two  kidneys,  one  may  be 
normal  and  act  as  a  standard  of  comparison  for  the  other,  or  there 
may  be  signs  of  disease  in  each. 

The  quantity  of  urine  is  occasionally  reduced  by  the  presence 
of  the  catheter  in  the  ureter.  This  is  usually  temporary,  and 
can  be  avoided  by  giving  a  diuretic  before  the  examination. 
The  quantity  may  be  reduced  or  the  urine  be  absent  on  one 
side  from  blocking  of  the  ureter  or  advanced  disease  of  the 
kidney.  There  may  be  polyuria  on  the  diseased  side  in  conditions 
of  cystitis  such  as  early  renal  tuberculosis. 

The  urine  should  be  examined  for  blood,  pus,  epithelial 
elements,  and  crystals,  and  also  for  bacteria. 

The  renal  function  is  tested  by  the  methods  already  described. 
Those  suitable  for  the  examination  of  one  kidney  are  the  quanti- 


XXVII]       EXAMINATION   OF  EACH   URINE 


373 


tative  estimation  ot  urea,  Casper's  phloridzin  test,  Albarran's  ex- 
perimental polyuria  test,  and  the  pJK'nol-sulj)liono-phthaleiii  test. 
I  use  the  phloridzin  and  phenol-suiphone-phthalein  tests,  and 
retain  the  catheters  for  two  or  three  hours. 

The  details  of  the  tests  of  the  renal  function  have  been  already 
described  (p.  20). 

The  following  table  gives  the  results  of  the  examination  of 
the  urine  of  each  kidney  in  a  case  in  which  nephrectomy  was 
performed  for  advanced  calculous  disease  of   the  right  kidney : — 


BIGHT   KIDNEY 

LEFT   KIDNEY 

Quantity 

206-5  c.c. 

107   C.C. 

Specific  gravity 

1004. 

1011. 

Freezing-point  (a) 

-018  C. 

-0-76  C. 

Colour    . . 

Pale,  limpid. 

Fairly  coloured. 

Urea 

0-4  per  cent. 

1-3  per  cent. 

Uric  acid 

0-0067  per  cent. 

00150  per  cent. 

Chlorides  as  chlorine  . . 

0-09777  per  cent. 

01 112  per  cent. 

Phosphates  as  P2O5     . . 

0-08  per  cent. 

0-034  per  cent. 

Methylene  blue . . 

No  change  in  colour. 

Appeared  in  1  hour   50 
minutes,  green  colour, 
duration  18  hours. 

Chromogen 

Appeared  in  25  min- 

Appeared   in     25    min- 

utes, faint  green. 

utes,  deep  green. 

Phloridzin  glycosuria   . . 

0-395  grm. 

1-623  grm. 

The  following  is  a  report  on  a  case  in  which  nephrectomy  was 
performed  for  tuberculosis  of  the  left  kidney : — 


EIGHT   KIDNEY 


LEFT   KIDNEY 


Total  quantity  . . 

Specific  gravity 

Urea 

Phloridzin  glycosuria 


3  oz. 

1018. 

1-4  per  cent. 

2-81  grm. 

No  tubercle  bacilli. 


8  oz. 

1006. 

0-3  per  cent. 

Absent. 

Tubercle  bacilli 


LITERATURE 

Albarran,  Exploration  des  Fonctions  Renales.     1905. 
Casper  und  Richter,  Functionelle  Nierendiagnostik.     1901. 
Kapsammer,  Nierendiagnostik  und  Nierenchirurgie.     1907. 
Walker,  Thomson,  Renal  Function  in  Urinary  Surgery.     1908. 


CHAPTER  XXVIII 
VESICAL  SYMPTOMS  OF  DISEASE 

HEMATURIA  and  pyuria  have  already  been  discussed  [see  pp.  55,  62). 

Frequent  Micturition 

Increased  frequency  of  micturition  may  be  a  symptom  in 
almost  any  disease  of  the  bladder,  and  is  observed  also  in  many 
extra  vesical  diseases. 

The  normal  frequency  of  micturition  varies  in  different  indi- 
viduals, and  in  the  same  individual  under  varying  conditions. 

The  female  bladder,  by  habit,  is  emptied  less  frequently  than 
the  male.  The  average  number  of  micturitions  during  the  day 
is  three  or  four  in  the  female  and  four  to  six  in  the  male.  During 
the  night  there  is  no  call  to  micturate,  partly  from  training  and 
partly  from  the  smaller  quantity  of  urine  secreted.  Some  healthy 
individuals,  however,  rise  once  during  the  night  to  pass  water. 
This  may  be  the  continuation  of  a  habit  acquired  in  early  life,  or 
it  may  be  the  functional  sequence  of  some  pathological  condition 
of  the  bladder,  the  organic  disease  having  long  passed  off.  The 
senile  bladder  is  less  sensitive,  and  micturition  is  usually  performed 
less  frequently  than  in  earlier  life.  In  old  men  increased  diurnal 
frequency  and  the  necessity  for  nocturnal  micturition  are  signs 
of  disease.  In  the  tropics  urine  is  passed  less  frequently  than  in 
cold  climates,  owing  to  the  smaller  quantity  secreted.  On  return- 
ing from  the  tropics  to  the  temperate  zone,  frequent  micturition 
is  usually  observed.  It  may  be  distressing,  and  occasionally 
persists  for  some  years.  An  Indian  civil  servant  has  told  me 
that  for  over  two  years  after  returning  to  England  from  India 
he  and  his  wife  were  unable  to  accept  an  invitation  to  dinner 
on  account  of  frequent  micturition.  For  convenience  of  de- 
scription, frequency  of  micturition  will  be  considered  under  four 
headings  : 

1.  Frequency  of  polyuria. — In  diabetes  mellitus,  diabetes 
insipidus,  chronic  Bright' s  disease,  chronic  interstitial  nephritis 
from  obstructive  disease,  nervous  polyuria,  and  in  the  transient 
forms  of  polyuria  such  as  those  due  to  diuretics  (tea,  etc.),  there 

374 


CHAP.  XXVIII]     FREQUENT   MICTURITION  375 

is  increased  frecjuency  of  inicturitioii.  The  increased  frequeocy 
is  nocturnal  as  well  as  diurnal.  In  nephritis  from  obstructive  dis- 
ease the  nocturnal  frequency  is  especially  marked.  The  quantity 
of  the  urine  and  the  presence  of  abnormalities  such  as  sugar  or 
albumin  render  the  diagnosis  obvious. 

2.  Frequency  with  normal  urine  and  bladder. — The  mental 
state  may  affect  the  frequency  of  micturition.  Fear  and  excite- 
ment may,  apart  from  the  production  of  polyuria,  cause  frequency. 
Prolonged  intense  concentration  may  reduce  frequency.  When 
disease  of  the  bladder  is  present  mental  influences  still  affect  the 
frequency  of  micturition.  A  patient  with  frequent  micturition 
due  to  disease  may  have  prolonged  intervals  when  his  attention 
is  fully  occupied,  and  shorter  intervals  when  there  is  nothing  to 
distract  his  attention  from  the  calls  to  micturate. 

Reflex  frequency  may  be  caused  by  disease  of  the  kidneys. 
It  is  difficult  to  dissociate  this  from  irritation  of  the  bladder  by 
descending  ureteritis  or  by  irritating  urine.  In  early  tuber- 
culosis of  the  kidney,  as  well  as  in  some  cases  of  movable  kidney 
and  calculus,  there  is  ground  for  believing  that  an  increased  fre- 
quency of  micturition  may  be  reflex,  for  the  cystoscopic  appear- 
ance of  the  bladder  and  .ureteric  orifices  is  normal.  In  other  and 
advanced  diseases  of  the  kidney  and  ureter,  such  as  pyelonephritis, 
stone,  tuberculosis  of  the  kidney  and  ureter,  inflammation  of  the 
bladder  base  is  present  and  is  the  cause  of  the  frequency.  In 
such  cases  the  diagnosis  as  to  the  presence  or  absence  of  bladder 
disease  is  made  by  means  of  the  cystoscope. 

Reflex  frequency  of  micturition  may  have  its  source  in  rectal 
irritation  caused  by  worms,  a  condition  which  is  often  the  cause 
of  enuresis  in  children.  In  cases  of  rectal,  anal,  or  vulvar  irrita- 
tion increased  frequency  of  micturition  is  often  due,  not  to  reflex 
influences,  but  to  a  mild  form  of  cystitis,  with  or  without  bacilluria, 
or  there  may  be  some  disease  such  as  diabetes. 

Pressure  on  a  normal  bladder  from  without  causes  frequent 
micturition  by  reducing  its  capacity.  Frequency  is  sometimes 
a  marked  and  distressing  symptom  in  the  later  months  of  preg- 
nancy, and  is  generally  associated  with  an  abnormal  position  of 
the  foetus  (retroversion).  I  have  been  consulted  in  regard  to 
persistent  frequency  in  a  young  lady  which  I  found  was  due  to 
the  pressure  of  a  large  ovarian  cyst. 

3.  Frequency  due  to  irritating  urine. — Apart  from  other 
causes  the  urine  may  cause  irritability  in  a  healthy  bladder. 

Blood  poured  out  suddenly  and  in  quantity  may  cause  frequent 
micturition  ;  usually,  however,  no  change  is  caused  by  hsema- 
turia  in  the  frequency  of  micturition.     Where  clots  are  formed 


376  THE  BLADDER  [chap. 

they  may  act  as  foreign  bodies  and  give  rise  to  frequency.  It  is 
more  usual  to  find  that,  beyond  a  temporary  difficulty  during  the 
passage  of  the  clot  along  the  urethra,  the  patient  is  unaware  of 
any  irritation. 

When  the  urine  is  highly  acid,  when  it  contains  abundance  of 
oxalate-of-lime  crystals,  or  is  milky  with  phosphates,  extreme 
irritability  of  the  bladder  is  present.  In  any  of  these  states  of 
the  urine,  but  especially  in  phosphaturia,  the  irritability  of  the 
bladder  is  intermittent.  It  is  more  pronounced  at  certain  times 
of  the  day ;  in  phosphaturia  it  is  often  worse  after  dinner.  Bacil- 
luria  may  be  the  cause  of  persistent  frequency  without  other 
symptoms. 

4.  Frequency  from  disease  of  bladder,  prostate,  or  urethra. 
— The  frequency  in  mild  cystitis  is  diurnal,  but  in  severe  cystitis 
it  is  also  nocturnal,  and  the  patient  passes  water  at  regularly 
spaced  intervals  of  half  to  one  or  two  hours  day  and  night,  accord- 
ing to  the  intensity  of  the  inflammation  and  its  distribution  in 
the  bladder.  The  frequency  is  unaffected  by  movement,  but  the 
intervals  may  be  longer  when  the  attention  of  the  patient  is  held 
by  other  matters.  In  new  growth  frequent  micturition,  if  present, 
is  due  to  cystitis  and  has  the  characters  already  described. 

The  frequency  due  to  stone  in  the  bladder  is  characteristic.  It 
is  present  during  the  day  and  disappears  at  night  or  on  resting. 
Movements  and  exercise,  or  travelling  by  train  or  motor-car, 
increase  the  frequency.  If  there  be  severe  cystitis  the  frequency 
is  present  at  night  as  well  as  during  the  day. 

In  enlarged  prostate  there  is  an  increase  in  the  diurnal  frequency, 
and  the  patient  rises  once  or  several  times  during  the  night.  The 
first  four  or  five  hours  of  the  night  are  usually  undisturbed,  and 
then  the  patient  wakes  at  three  or  four  o'clock  and  passes  water, 
and  this  is  repeated  several  times  at  short  intervals.  Movement 
and  exercise  have  no  effect  upon  prostatic  frequency. 

The  frequency  which  results  from  urethritis  of  the  prostatic 
urethra  usually  accompanies  a  urethral  discharge.  It  is  diurnal, 
and  occasionally  nocturnal,  in  character. 

Frequent  micturition  due  to  nervous  disease  will  be  considered 
later. 

Treatment. — The  treatment  of  frequent  micturition  depends 
upon  the  cause,  and  the  reader  is  referred  to  the  various  diseases 
which  produce  increased  frequency  of  micturition  for  the  lines 
along  which  treatment  should  be  conducted.  When  the  frequency 
is  unconnected  with  any  pathological  condition  of  the  urine  or 
bladder,  the  prognosis  for  complete  recovery  is  good  only  in  mild 
cases.     Washing  the  bladder  with  weak  nitrate  of  silver  solution 


XXVIII]  INCONTINENCE   OF  URINE  377 

(1  in  10,000)  or  with  a  5  per  cent,  solution  of  antipyrin,  or  gradual 
dilatation  by  the  injection  of  progressively  increasing  quantities 
of  fluid,  may  be  tried,  or  instillations  of  silver  nitrate  solution 
(1  or  2  per  cent.)  into  the  deeper  part  of  the  urethra,  or  of  cocaine 
(1  per  cent.)  or  other  local  anaesthetic,  may  be  given  at  intervals 
of  a  week.  Gomenol  may  be  instilled  in  small  quantities  (1  or 
2  drachms  of  5  or  10  per  cent.)  once  or  twice  a  week. 

Electricity  in  the  form  of  X-rays  or  high-frequency  currents 
or  radiant  heat  has  been  employed,  but  is  rarely  successful.  Treat- 
ment by  suggestion  may  be  tried  in  severe  cases. 

The  following  drugs,  which  should  be  given  with  caution  when 
urethral  or  prostatic  obstruction  is  present,  are  valuable  in  reducing 
frequency,  viz.  camphor  (2  gr.  in  pill)  or  camphor  monobromide 
(2-4  .gr.  in  suppository),  cannabis  indica  (tincture  in  doses  of 
5-10  minims,  or  extract  in  doses  of  |  gr.  in  pill),  belladonna 
(tincture,  5-10  minims,  extract,  i  gr.,  in  suppository),  coUinsonia 
canadensis  (tincture,  |-1  drachm,  liquid  extract,  1-2  drachms,  or 
as  suppository  20  gr.),  sandal-wood  oil  (10  minims  in  capsule),  oil 
of  copaiba  (5-15  minims  in  capsule),  hydrastis  canadensis  (tinc- 
ture, 30-60  minims),  kava-kava  (liquid  extract,  30-60  minims), 
argopyrum  (decoction,  .^1  oz.,  or  liquid  extract,  1-2  drachms), 
hyoscyamus  (tincture,  10-15  minims),  lupulin  (pill  containing 
2-5  gr.,  or  suppository  5  gr.),  lycopodium  (tincture,  15-60  minims). 

When  the  urine  is  highly  acid,  diuretics  and  alkalis  should 
be  administered,  such  as  Contrexeville,  Vittel,  or  Evian  waters, 
acetate  or  citrate  of  potash  (15-20  gr.),  liquor  potassse  (5-10  minims), 
and  sodium  bicarbonate  (5-30  gr.). 

If  phosphaturia  is  present,  sodium  acid  phosphate  (20  gr.)  and 
mineral  acids  should  be  prescribed  {see  p.  49). 

Incontinence  of  Urine 

Incontinence  consists  in  the  involuntary  escape  of  urine  from 
the  bladder,  and  is  due  to  very  widely  differing  causes. 

The  urine  is  retained  in  the  bladder  by  the  combined  action 
of  the  involuntary  sphincter  at  the  outlet  of  the  bladder  and  the 
voluntary  compressor  urethras  or  external  sphincter. 

In  infancy  the  bladder  acts  in  an  automatic  reflex  manner. 
After  a  certain  quantity  of  urine  has  accumulated  it  is  expelled. 
Towards  the  end  of  the  first  year  mental  control  by  inhibition  is 
becoming  established,  and  at  the  end  of  the  second  year  the  child 
has  learned  to  intimate  the  desire  to  micturate  and  to  exert  an 
inhibiting  influence  for  a  certain  time  during  the  waking  hours. 
Inhibition  of  micturition  during  sleep  becomes  gradually  estab- 
lished, and  under  normal  conditions  and  surroundings  is  complete, 


378  THE   BLADDER  [chap. 

except  for  an  occasional  accident,  at  the  end  of  the  second  year. 
During  adult  life  the  voluntary  power  of  inhibiting  micturition 
during   waking   hours   and  the   unconscious   inhibition   exercised 
during  sleep  are  much  more  powerful  and  less  easily  disturbed. 
Incontinence  of  urine  may  be  (1)  false,  (2)  true. 

(1)  False  incontinence. — ^Here  the  bladder  is  full  of  urine, 
and  the  escape  is  the  overflow  from  the  over-distended  organ. 
This  is  observed  in  cases  of  chronic  retention  due  to  prostatic  or 
urethral  obstruction. 

(2)  In  true  incontinence  the  urine  which  escapes  is  the 
entire  content  of  the  bladder.     Two  types  can  be  distinguished : 

(a)  A  fassive  type,  in  which  the  urine  dribbles  away  without 
distending  the  bladder  and  without  contraction  of  the  bladder 
assisting  the  expulsion.  Here  the  sphincter  is  paralysed,  and  to 
this  type  belong  cases  of  paralysis  of  the  bladder  involving  the 
sphincter,  or  paralysis  of  the  sphincter  by  mechanical  means. 

(6)  An  axitive  type,  in  which  the  urine  is  expelled  by  contraction 
of  the  bladder.  Here  there  is  sphincter  action,  but  it  is  either 
too  weak  to  resist  the  normal  contractions  of  the  bladder  or  the 
contractions  are  so  strong  as  to  overcome  a  normal  sphincter. 

1.  Incontinence  due  to  mechanical  causes. — This  occurs 
more  frequently  in  women  than  in  men.  A  slight  occasional 
escape  of  urine  on  coughing,  sneezing,  or  lifting  weights,  or  on 
exertion  of  any  kind  such  as  playing  golf,  is  sometimes  observed 
in  women.  In  slight  cases  it  may  be  difl&cult  to  assign  a  cause, 
but  it  is  probably  traumatic,  for  it  frequently  follows  parturition. 
In  older  women  more  serious  incontinence  occurs  in  combination 
with  cystocele. 

When  the  now  obsolete  method  of  examination  of  the  female 
bladder  by  dilatation  of  the  urethra  and  introduction  of  the  finger 
was  in  vogue,  incontinence  of  urine  from  overstretching  of  the 
sphincter  was  commonly  observed.  Injury  sustained  during  child- 
birth may  cause  incontinence. 

In  men  perineal  prostatectomy  may  produce  incontinence  of 
urine.  I  have  also  known  it  follow  perineal  drainage  of  the  pros- 
tatic cavity  after  suprapubic  prostatectomy,  being  caused  by 
cutting  through  the  compressor  urethrae  muscle,  which  acts  as  the 
vesical  sphincter  in  these  cases. 

In  a  few  cases  (5  per  cent.)  of  malignant  disease  of  the  prostate 
there  is  incontinence  of  urine  without  distension  of  the  bladder. 
In  these  cases  there  is  extensive  infiltration  of  the  bladder  base, 
and  the  prostatic  urethra  is  open  and  rigid. 

Treatment. — In  slight  cases  in  women  medicine  may  suffice. 
Strychnine   (liquor,    5  minims)   and  ergot   (liquid  extract,    10-20 


XXVIII]  INCONTINENCE   OF   URINE  379 

luinims)  are  the  best  drugs.  The  introduction  of  a  pessary  may 
control  the  escape  l)y  pressure  upon  tfie  uretlira.  In  some  severe 
cases  operation  is  necessary.  When  cystocele  is  present  an  ellip- 
tical portion  with  the  long  axis  vertical  should  be  removed  from 
the  anterior  vaginal  wall  and  the  edges  united. 

Duret  has  freed  the  urethra  and  excised  the  mucous  mem- 
brane around  its  orifice,  and  transplanted  the  urethra  forwards 
to  the  neighbourhood  of  the  clitoris. 

Gersuny  dissects  the  female  urethra  with  as  much  surrounding 
tissue  as  possible,  twists  it  on  its  own  axis  for  a  complete  turn, 
and  fixes  it  in  this  position.  The  urethra  is  thrown  into  spiral 
folds  in  its  whole  length.  This  surgeon  has  also  injected  paraffin 
around  the  urethra  and  bladder  orifice  in  incontinence  of  urine  in 
the  female,  but  the  method  has  not  been  widely  adopted. 

Where  incontinence  in  the  male  follows  prostatectomy,  recovery 
or  improvement  may  take  place  by  the  perineal  muscles  assuming 
control.     If  not,  the  patient  will  have  to  wear  a  urinal. 

2.  Incontinence  due  to  nervous  disease. — This  form  of 
incontinence  is  considered  at  p.  532. 

3.  Incontinence  due  to  bladder  spasm. — The  somewhat 
rare  form  of  uncontrollable  bladder  spasm  met  with  in  disease  of 
the  spinal  cord  has  already  been  mentioned. 

In  acute  inflammation  of  the  bladder  uncontrollable  spasm 
may  give  rise  to  active  incontinence.  This  is  usually  nocturnal, 
as  the  patient,  worn  out  by  frequent  micturition,  sleeps  heavily 
and  the  urine  is  passed  involuntarily.  Tuberculosis  of  the  bladder 
in  its  advanced  stage  is  the  most  frequent  cause,  but  other  forms 
of  cystitis  which  persist  in  a  subacute  condition  may  also  cause 
incontinence  of  this  type. 

Diurnal  incontinence  from  uncontrollable  spasm  is  also  met 
with  in  the  acute  stages  of  cystitis  and  in  acute  inflammation  of 
the  prostate  and  prostatic  urethra. 

Treatment. — Means  of  soothing  the  bladder  should  be  adopted. 
In  acute  cases  hot  fomentations  should  be  applied  suprapubically 
and  on  the  perineum,  and  morphia  and  belladonna  suppositories 
given.  The  rectum  may  be  washed  out  with  hot  water,  followed 
by  a  small  enema  of  hot  water  containing  anti pyrin  (30  gr.)  to 
be  retained.  The  urine  should  be  diluted  and  rendered  less  irri- 
tating by  large  draughts  of  Contrexeville  or  Vittel  water,  and  by 
the  administration  of  sandal-wood  oil  (10  minims  in  capsule).  Hot 
sitz-baths  (106°-108°  F.)  are  sometimes  useful. 

In  chronic  cases  diuretics  and  sandal-wood  oil  should  be  ad- 
ministered and  belladonna  and  hyoscyamus  with  small  doses  of 
opium  given  in  mixture.     Gomenol  (5  per  cent.)  may  be  used  as  an 


380  THE   BLADDER  [chap. 

ingtillation  (30  to  60  minims)  in  the  bladder  and  given  by  mouth 
in  capsules.  The  treatment  of  the  cystitis  is  carried  out  simulta- 
neously with  these  measures.  In  tuberculous  cystitis  the  bladder 
should  not  be  washed. 

4l.  Incontinence  of  childhood  (nocturnal  enuresis,  essen- 
tial enuresis). — Up  to  the  end  of  the  first  year  the  bladder  acts 
automatically.  About  that  time,  as  mentioned  above,  mental  con- 
trol of  the  act  of  micturition  begins,  and  by  the  age  of  18  months 
or  at  most  2  years  it  is  fairly  established.  At  first  the  control  is 
feeble  and  the  inhibition  can  only  be  exercised  for  a  very  short 
time,  and  during  sleep  the  automatic  action  continues.  Gradually 
the  control  grows  stronger  and  becomes  a  habit,  so  that  it  is 
exercised  during  the  hours  of  sleep,  although  there  may  still  be 
occasional  lapses  up  to  the  age  of  3  years.  After  that,  constant 
or  frequent  bed-wetting  must  be  regarded  as  abnormal.  The 
period  during  which  the  incontinence  of  childhood  occurs  extends 
from  the  age  of  3  to  puberty.  In  60  per  cent,  of  Still's  cases  the 
onset  was  observed  between  the  ages  of  5  and  8  years,  when  the 
second  dentition  commences. 

Enuresis  is  usually  nocturnal,  sometimes  it  is  diurnal  as  well, 
rarely  it  is  diurnal  only. 

There  may  have  been  a  period  of  a  year  or  more  of  complete 
control  before  the  enuresis  develops,  or  the  nocturnal  control 
may  never  have  become  established. 

In  142  cases  examined  by  Still,  67  had  been  incontinent  since 
birth,  and  in  75  the  incontinence  began  some  time  after  infancy. 

Boys  and  girls  are  about  equally  affected. 

Etiology. — i.  The  cases  first  to  be  considered  are  those  in 
which  a  source  of  irritation  is  found,  such  as  threadworms,  anal 
fissure,  vulvitis,  phimosis,  and  balanitis.  These  cases  are  looked 
upon  as  due  to  reflex  irritation.  The  relation  of  phimosis  to 
enuresis  is  doubtful.  The  great  majority  of  cases  that  have  come 
under  my  notice  have  already  been  circumcised  in  the  hope  of 
curing  the  enuresis,  but  without  any  effect  upon  it. 

In  some  cases  there  are  enlarged  tonsils  and  adenoids,  and  the 
enuresis  is  ascribed  to  partial  asphyxia  during  sleep.  The  import- 
ance of  this  as  a  causal  factor  is  disputed,  but  most  authorities 
are  agreed  that  where  enlarged  tonsils  and  adenoids  are  present 
their  removal,  or,  if  small,  the  use  of  breathing  exercises,  should 
form  an  adjunct  to  the  treatment  of  the  enuresis. 

ii.  The  next  group  of  cases  are  those  in  which  there  is  some 
abnormality  in  the  urine  or  disease  of  the  bladder.  In  young 
children  the  urine  may  be  highly  acid  and  contain  large  quantities 
of  uric  acid.     Phosphaturia  also  occurs  at  this  age.     Bacilluria  due 


xxvin]      INCONTINENCE   OF   CHILDHOOD  381 

to  the  bacillus  coli  is  a  common  disease  of  childhood,  and  explains 
a  small  number  of  cases.  Cystitis,  stone  in  the  bladder,  and  tuber- 
culous cystitis  may  be  found. 

iii.  Finally,  there  are  cases  in  which  no  source  of  irritation  and 
no  alteration  in  the  urine  or  disease  of  the  bladder  can  be  found. 
These  form  a  class  that  has  been  named  essential  enuresis.  There 
is  frequently  an  heredity  of  nervous  disease  which  may  take  the 
form  of  epilepsy,  neurasthenia,  alcoholism,  insanity,  or  other 
disease.  The  child  may  be  nervous,  quiet,  sensitive,  and  furtive. 
This  is  largely,  however,  due  to  a  feeling  of  shame,  and  sometimes 
to  the  well-meaning  but  cruel  and  utterly  futile  attempts  of  parents 
or  guardians  to  bring  about  a  cure  by  chastisement.  Stuttering 
and  habit  spasms  are  frequently  observed,  and  betray  a  lack  of 
co-ordination  in  the  nerve  centres.  In  some  children  there  is  a 
slight  escape  of  urine  on  coughing  or  exertion,  together  with 
nocturnal  enuresis. 

The  enuresis  is  always  worse  after  excitement.  It  may  occur 
when  the  child  is  at  school  and  cease  during  holidays. 

In  a  small  number  of  cases  the  enuresis  occurs  during  a  minor 
epileptic  seizure ;  and  the  possibihty  of  the  patient  suffering 
from  fetit  mal  must  .always  be  remembered.  Thursfield  points 
out  that  in  these  cases  the  interval  between  the  bed-wettings  is 
much  greater,  and  may  be  one  or  two  months,  and  then  several 
wettings  occur  in  succession. 

Prognosis. — In  cases  where  an  abnormality  is  found  which 
is  amenable  to  treatment  the  prognosis  for  immediate  recovery 
is  good. 

In  the  great  majority  of  cases  of  essential  enuresis,  continence 
becomes  complete  with  or  before  the  advent  of  puberty.  Most 
cases  get  well  after  two  or  three  months'  treatment,  but  some- 
times treatment  for  a  year  or  even  longer  is  required.  In  a  small 
percentage  enuresis  persists  into  adult  life. 

Treatment. — In  cases  where  some  reflex  influence,  such  as 
threadworms,  is  a  factor,  this  should  be  treated.  The  prognosis 
should,  however,  be  guarded,  for  the  removal  of  a  source  of  irrita- 
tion may  not  be  attended  by  the  disappearance  of  the  enuresis. 
Circumcision  is  often  disappointing  in  this  respect.  This  operation, 
and  also  that  for  the  removal  of  enlarged  tonsils  and  adenoids, 
should,  nevertheless,  always  be  done  as  a  preliminary  to  other 
treatment. 

Hyperacid  urine  with  uric-acid  or  oxalate  crystals  should  be 
treated  with  alkalis  (potass,  citrate,  5  or  10  gr.  for  a  child  of  3  or 
5  years),  and  the  intake  of  carbohydrates  should  be  cut  down. 
Sugar,    starch,  green  vegetables,   potatoes,   and  fruits  should   be 


382  THE  BLADDER  [chap. 

restricted.     This  is  more  important  than  interdicting  nitrogenous 
foods. 

Phosphaturia  is  treated  with  acids  and  sodium  acid  phos- 
phate, and  attention  to  the  diet  and  bowels.  Bacilluria,  cystitis, 
and  stone  should  receive  appropriate  treatment. 

In  cases  where  all  such  causes  of  irritation  are  absent,  treat- 
ment along  the  following  lines  should  be  adopted :  All  sources  of 
mental  excitement  should  be  excluded.  Late  hours,  theatres, 
parties,  entertainments  of  all  kinds,  should  be  interdicted.  The 
efEect  of  removing  the  child  from  school  and  reducing,  or  for  a 
time  intermitting,  book-work  should  be  tried. 

If,  as  sometimes  happens,  the  enuresis  ceases  when  the  child 
is  withdrawn  from  school,  a  three  or  six  months'  holiday  should 
be  prescribed.  Country  life  in  the  open  air  is  to  be  preferred 
to  town  life. 

The  principal  meal  should  be  taken  in  the  middle  of  the  day, 
and  no  fluids  should  be  allowed  after  five  o'clock.  Tea  and  cofiee, 
ginger  beer  and  ginger  ale  should  be  interdicted.  Meat  may  be 
taken,  but  in  moderate  quantities.  All  highly  seasoned  foods, 
with  sugars'  and  pastry,  should  be  avoided.  The  nurse  should 
train  the  child  to  hold  water  at  longer  periods  during  the  day, 
and  the  child  should  be  made  to  pass  water  before  going  to  rest. 
He  should  be  wakened  for  the  same  purpose  once  during  the  night. 
The  enuresis  usually  occurs  during  the  first  two  hours  of  sleep, 
and  the  nocturnal  micturition  should  be  arranged  to  take  place 
after  about  one  and  a  half  hours'  sleep,  shortly  before  it  is  due. 
The  mattress  should  be  firm,  and  the  clothing  light  but  warm. 
The  air  of  the  bedroom  should  not  be  too  cold. 

Belladonna  is  largely  used  in  the  form  of  the  tincture.  The 
dose  varies  Math  the  age  and  idiosyncrasy  of  the  patient.  It  should 
commence  with  3  minims  of  the  tincture  thrice  daily  for  a  child 
of  5  years  or  over,  and  slowly  increase  up  to  30  or  40  minims,  or 
even  1  drachm,  three  times  a  day,  unless  symptoms  of  dryness  of 
the  throat,  flushing,  dim  vision,  and  commencing  delirium  appear. 
During  the  period  in  which  this  drug  is  being  administered  the 
child  should  be  under  daily  medical  supervision.  Symptoms  of 
poisoning  with  these  large  doses  may  set  in  rapidly.  If  the  enuresis 
is  controlled  the  dose  should  be  kept  a  little  beyond  this  point 
for  a  fortnight  and  then  very  gradually  reduced. 

Tincture  of  lycopodium  is  also  useful  and  may  be  combined 
with  belladonna.  The  dosage  should  commence  with  5  or  10 
minims  thrice  daily,  and  may  rise  to  20  minims.  The  tincture  of 
nux  vomica  in  doses  of  3  or  4  minims  thrice  daily  for  a  child  of  5, 
and  the  liquid  extract  of  ergot  in  doses  of  10-20  minims  thrice 


xxviii]      INCONTINENCE   OF  CHILDHOOD  383 

daily,  are  sometimes  successful.  I  have  found  them  most  useful 
in  cases  where  an  occasional  leak  on  laughing,  sneezing,  or  other 
muscular  effort  shows  weakness  of  the  sphincter. 

Potassium  bromide  and  antipyrin  have  been  found  useful,  and 
the  fluid  extract  of  rhus  aromatica  in  doses  similar  to  bella- 
donna is  recommended  (Still).  Hyoscine  hydrobromide  has  also 
been  used. 

Leonard  Williams  and  Firth  have  used  thyroid  extract.  The 
latter  observer  found  that  of  28  cases  16  showed  a  marked  improve- 
ment or  were  cured,  and  12  showed  no  improvement.  The  initial 
dose  was  J  gr.,  and  this  was  cautiously  increased  to  1  gr.  or  even 
4|-  gr.  in  twenty-four  hours.  The  treatment  was  most  successful 
when  the  child  was  backward,  slow  at  school,  lethargic,  and 
under  weight. 

Local  treatment  should,  if  possible,  be  avoided,  but  in  some 
cases  it  may  be  used  and  be  successful. 

Instillation  of  10  or  15  minims  of  silver  nitrate  solution  (1  per 
cent.)  into  the  prostatic  urethra  once  a  week  for  three  or  four  weeks 
may  be  followed  by  cessation  of  the  enuresis.  I  have,  however, 
known  relapses  occur  after  this  treatment  when  it  was  completely 
successful  for  a  time. 

Treatment  by  the  continuous  current  is  applied  by  means  of 
a  urethral  electrode  introduced  into  the  prostatic  urethra  and  a 
pad  applied  over  the  suprapubic  region.  Two  or  three  seances 
are  given  for  five  or  ten  minutes,  with  a  week's  interval 
between. 

Cathelin  has  suggested  the  injection  of  fluid  into  the  sacral 
canal  with  the  object  of  causing  pressure  upon  the  sacral  nerves. 
The  method,  which  is  employed  also  for  adults,  is  carried  out  in 
the  following  manner :  The  patient  is  placed  upon  the  side  with 
the  back  bent  and  the  thighs  well  flexed  upon  the  abdomen.  With 
the  tip  of  the  forefinger  the  opening  at  the  lower  end  of  the  sacral 
canal  is  defined.  This  opening  is  covered  with  a  membrane  and 
lies  a  short  distance  above  the  lower  end  of  the  sacrum.  On  each 
side  of  it  is  a  tubercle,  and  the  bony  arch  surrounding  the  small 
opening  can  be  felt.  The  skin  is  carefully  cleaned  and  a  hypo- 
dermic syringe  sterilized  and  filled  with  30  minims  of  saline  solu- 
tion. The  needle  is  passed  through  the  membrane  and  easily 
introduced  into  the  sacral  canal.  The  fluid  is  slowly  injected  and 
the  needle  removed.  The  procedure  is  painless.  Cathelin  claims 
80  per  cent,  of  cures  by  this  method.  I  have  used  it  in  a  few 
obstinate  cases,  but  have  had  no  success  with  it. 

Care  should  be  devoted  to  training  the  child,  and  when  the 
confidence  is  once  gained  much  may  be  done  by  persuasion.     Good 


384  THE   BLADDER  .  [chap. 

results  have  been  claimed  for  control  by  suggestion,   employed 
during  waking  hours  and  also  during  sleep. 

LITERATURE 

Dudgeon,  Lancet,  1908,  i.  616. 
Firth,  Lancet,  1911,  ii.  1619. 
Still,  Diseases  of  Children. 
Williams,  Lancet,  1909,  i.   1245. 

Difficult  Mictueition 

Difficult  micturition  results  from  obstruction  to  the  outflow 
of  urine,  or  from  reduced  power  of  expulsion. 

In  difficult  micturition  there  is  delay  in  the  commencement 
of  the  act  amounting  to  from  a  few  seconds'  hesitation  to  a  wait 
of  two  minutes  or  more.  The  stream  is  feebly  projected,  and 
may  drop  vertically  from  the  end  of  the  penis.  It  may  commence 
feebly,  and  gain  in  power,  and  then  fall  away  again,  or  it  may 
dribble  throughout.  The  stream  may  be  intermittent,  one  or 
several  pauses  occurring  during  the  act.  Occasionally  the  flow 
ceases,  and  only  recommences  after  a  pause  of  several  minutes, 
or  even  a  quarter  of  an  hour.  The  abdominal  muscles  are  brought 
forcibly  into  action  to  assist  the  expulsion  of  the  urine.  After- 
dribbling  is  usually  observed. 

The  most  frequent  cause  of  difficult  micturition  is  stricture 
of  the  urethra.  Here  the  obstruction  usually  commences  in  young 
men,  or  below  the  age  of  45.  The  onset  is  insidious,  and  the 
increase  is  gradual  and  persistent.  Attacks  of  retention  of  urine 
following  alcoholic  excess  or  exposure  to  cold  or  wet  supervene 
when  the  stricture  has  become  narrow.  Eventually  there  may 
be  chronic  retention  with-  overflow. 

Diseases  of  the  prostate  frequently  cause  difficult  micturition. 
The  commonest  of  these  is  simple  enlargement  of  the  gland.  Here 
the  symptoms  commence  at  or  after  the  age  of  50  years.  The 
difficulty  is  combined  with  frequency  of  micturition,  which  is 
most  troublesome  at  night  and  especially  during  the  early  hours  of 
the  morning.  Complete  retention  may  occur  without  the  patient 
being  aware  of  previous  difficulty  in  micturition.  Malignant  disease 
of  the  prostate  causes  difficult  micturition  which  closely  resembles 
that  of  stricture ;  it  is  insidious  and  persistent  and  is  not  com- 
bined with  frequent  micturition  unless  cystitis  is  present,  but  it 
appears  in  middle  or  late  life.  Tuberculous  disease  and  calculi  of 
the  prostate,  subacute  chronic  inflammation  of  the  prostatic  urethra, 
post-gonorrhoeal  or  due  to  bacillus  coli,  may  cause  difficulty  of  mic- 
turition. Acute  urethritis,  prostatic  abscess,  impaction  of  a  stone 
in  the  prostatic  urethra,  may  cause  difficulty  and  even  retention. 


XXVIII]  RETENTION   OF  URINE  385 

Atony  of  the  bladder,  apart  from  obstruction,  is  usually  due 
to  disease  of  the  spinal  cord.  The  patient  complains  of  increas- 
ing difficulty  of  micturition,  or  sometimes  there  is  sudden  com- 
plete retention.  Tabes  and  Erb's  "  syphilitic  spinal  paralysis  "  are 
the  most  frequent  causes  of  this  form  of  atony.  The  symptom 
is  often  combined  with  nocturnal  incontinence  without  over- 
distension of  the  bladder.  I  have  described  a  form  of  atony  of 
the  bladder  without  obstruction  and  without  signs  of  nervous 
disease  ;  it  occurs  at  any  age,  but  most  frequently  in  young  men  ; 
the  cases  do  not  at  a  later  date  develop  symptoms  of  spinal  disease. 

Functional  difficulty  of  micturition.  Stanhnnering  blad- 
der.— It  is  well  known  that  micturition  may  be  difficult  or  impossible 
when  there  is  urgent  necessity  that  it  should  be  quickly  performed, 
or  when  it  is  attempted  in  the  presence  of  others.  There  are 
many  patients  who  pass  water  after  considerable  hesitation,  or 
are  unable  to  pass  it  at  all,  when  called  upon  to  do  so  in  the 
surgeon's  consulting-room.  These  are  the  minor  phases  of  the 
condition  described  by  Sir  James  Paget  as  the  "  stammering 
bladder."  In  its  more  severe  forms  it  is  found  that  otherwise 
healthy  individuals  cannot  pass  water  in  a  public  urinal,  and  may 
get  complete  retention  of  urine  (hysterical  retention).  Complete 
retention  from  this  cause  occurs  more  frequently  in  women. 

Treatment. — The  treatment  of  difficult  micturition  can  only 
be  initiated  after  the  cause  has  been  ascertained.  Urethral 
obstruction  due  to  stricture  is  treated  by  dilatation  or  operation, 
enlarged  prostate  by  operation.  The  obstruction  of  malignant 
disease  of  the  prostate  is  much  benefited  by  the  careful  passage 
of  metal  instruments  at  regular  intervals.  The  treatment  of 
atony  of  the  bladder  due  to  nervous  disease  will  be  discussed 
later  (p.  538). 

In  any  case  of  difficult  micturition  where  obstruction  has  been 
relieved,  or  where  a  paralysed  bladder  is  being  emptied  by  catheter, 
the  administration  of  small  doses  of  ergot  (liquid  extract,  15-20 
minims)  and-  strychnine  (liquor,  5  minims)  is  beneficial. 

In  "  stammering  bladder  "  ergot  and  strychnine  are  the  most 
useful  drugs,  and  they  may  be  combined  with  bromides. 

Ketention  of  Urine 

Etiology. — The  causes  of    retention    of    urine  may  be  classi- 
fied in  the  following  manner  : — 
1.  Retention   with   obstruction. 

(a)  Prostate. 

(1)  Simple  enlargement. 

(2)  Malignant  disease. 


386  THE   BLADDER  [chap. 

(3)  Stone. 

(4)  Acute  prostatitis  and  prostatic  abscess. 
(6)  Urethra. 

(1)  Rupture  of  urethra. 

(2)  Acute  urethritis. 

(3)  Stricture. 

(4)  Stone  and  foreign  bodies. 

(5)  Pressure  from  without,  pelvic  tumours,  etc. 

2.  Retention    due   to   atony. 

[a)  With  symptoms  of  nervous  disease. 

Tabes,  etc. 

(b)  Without  symptoms  of  nervous  disease. 

Idiopathic  atony. 

3.  Retention    in    acute   or    chronic    intoxications,    such   as 

appendicitis,   typhoid,    salpingitis,   or    arsenical,    mer- 
curial, belladonna,  or  lead  poisoning,  or  syphilis. 

4.  Retention  from  inhibition  or  spasm. 

(1)  Hysterical  retention. 

(2)  Retention  after  anal  and  rectal  operations. 
Diagnosis. — It  is   necessary    to    distinguish    between   anuria 

and  retention,  and  between  retention  due  to  atony  and  that  due 
to  obstruction,  and,  in  the  latter,  to  ascertain  the  form  of 
obstruction. 

A  patient  Avith  anuria  refers  to  previous  attacks  of  renal  colic,, 
haematuria,  or  other  signs  pointing  to  progressive  renal  disease, 
and  the  cessation  of  periodic  micturition  may  have  followed 
immediately  upon  such  an  attack.  Symptoms  of  bladder  trouble 
are  absent,  and  have  been  absent  or  insignificant  during  the  course 
of  the  disease.  The  patient  is  in  no  pain,  there  is  no  distension  of 
the  bladder,  and  an  instrument  passes  readily  along  the  urethra 
into  the  bladder  but  draws  no  urine.  In  retention  of  urine  there 
is  usually  a  history  of  gradually  increasing  difficulty  in  micturition, 
the  stream  has  become  progressively  smaller  and  more  feeble, 
and  there  may  be  some  involuntary  dribbling  of  urine.  The 
bladder  is  distended  and  appears  as  a  smooth,  rounded  swelling 
above  the  pubes,  firm  on  pressure  and  dull  on  percussion. 

In  retention  from  atony  of  the  bladder  muscle  there  is  no  pain 
and  no  desire  to  empty  the  distended  viscus.  In  acute  retention 
due  to  obstruction,  recurrent  spasmodic  attempts  of  the  bladder 
to  overcome  the  obstruction  usually  double  the  patient  up  with 
cramp-like  pain.  In  some  patients,  however,  pain  is  remark- 
ably absent,  and  this  is  especially  the  case  in  old  men  when  the 
obstruction  results  from  enlargement  of  the  prostate.  Here  the 
retention  is  chronic    and   slowly   progressive,  and   some   urine   is 


XXVIII]  RETENTION   OF  URINE  387 

passed,  voluntarily  or  involuntarily.  The  patient  may  be  unaware 
that  the  bladder  is  distended  even  when  the  organ  reaches  above 
the  umbilicus. 

Diagnosis  is  made  by  the  passage  of  a  large-sized  instrument, 
which  enters  the  bladder  easily  if  retention  is  due  to  atony,  but 
is  arrested  if  obstruction  is  present.  The  presence  of  signs  of  spinal 
disease  clinches  the  diagnosis.  In  young  men  the  most  frequent 
cause  of  acute  retention  is  gonorrhoea,  and  there  will  be  a  history 
of  an  acute  discharge.  In  adult  life  retention  is  usuallv  due  to 
stricture,  and  there  is  a  history  of  gradually  increasing  difficulty 
of  micturition,  culminating  in  retention  after  alcoholic  excess  or 
exposure  to  cold.  The  passage  of  an  instrument  confirms  the 
diagnosis.  In  old  men  enlargement  of  the  prostate  is  the  most 
frequent  cause  of  retention  of  urine.  There  is  a  history  of  noc- 
turnal frequency  and  increasing  difficulty,  and  rectal  examination 
shows  that  the  prostate  is  enlarged. 

Treatment. — The  follo\\nng  is  the  treatment  suited  to    the 
chief  t\'pes  of  cases  met  with  in  practice  : — 

1.  Acute  inflammation  of  the  urethra  {gonorrhcea,  etc.). — Every 
means  should  be  tried  to  relieve  the  retention  without  the  passage 
of  a  catheter.     Suprapubic  puncture  should  not  be  performed.     It 
has  been  recommended  with  the  view  of  avoiding  infection  of  the 
bladder   by  the   catheter  passing   along   the   urethra.     Retention 
does  not,  however,  take  place  unless  there  is  posterior  urethritis 
or  prostatitis,  and  in  such  cases  the  base  of  the  bladder  is  already 
infected.     The  patient  should  be  placed  in  a  hot  bath  or  made 
to  sit  in  a  hot  sitz-bath  and  directed  to  pass  his  water  in  it.     A 
large  hot- water  injection  should  be  introduced  into  the  rectum  ; 
should  this  fail,   a  suppository  containing  extract  of  belladonna 
(i  gr.)  and  aqueous  extract  of  opium  (f  gr.)  should  be  given.     If 
relief  is  not  obtained  in  half  to  three-quarters  of  an  hour  a  catheter 
must  be  passed  and  the  urine  withdrawn.     An  anaesthetic  will 
usually  be  necessary,  for  the  urethra  is  intensely  sensitive.     The 
canal  is  first  thoroughly  washed  with  a  solution  of  permanganate 
of   potash  (1    in  .5,000)  or  protargol   (1   in  10,000)  from  a  douche 
can,  a  glass  nozzle  and  bell  shield  being  used  to  allow  the  fluid 
to  rush  in  and  out  of  the  canal  without  splashing.     To  this  20  or 
30  minims  of  cocaine  solution  (2  per  cent.)  may  be  added  and 
may  suffice  to  numb  the  urethra  for  the  passage  of  the  instru- 
ment.    A  soft  rubber  catheter  is  passed  very  gently  and  the  urine 
withdrawn.      The  bladder  should  be  washed  out  with  protargol 
solution  before  the  catheter  is  removed.     If  a  morphia  and  bella- 
donna suppository  has  not  already  been   given,  it   should  now  be 
inserted    into   the   lectum   and   the   patient  returned  to  bed.     If 


388  THE   BLADDER  [chap. 

acute  prostatitis  and  a  prostatic    abscess    be    present,  operation 
as  soon  as  possible  is  indicated. 

2.  Blocking  the  urethra  hy  stone,  foreign  todies,  'pedunculated 
bladder  growths,  blood  clot,  etc. — The  diagnosis  is  made  by  the  his- 
tory, and  relief  by  catheter  should  be  given  without  delay.  There 
is  sometimes  difficulty  in  introducing  a  catheter,  due  to  intense 
spasm  of  the  compressor  urethree  muscle  caused  by  impaction 
of  the  stone  or  foreign  body.  A  metal  catheter  passes  most 
readily.  It  may  be  necessary  to  pass  several  metal  sounds  before 
the  catheter  can  be  introduced. 

The  distension  of  the  bladder  with  blood  clot  from  a  sudden 
copious  haemorrhage  in  a  case  of  bladder  growth  will  cause  re- 
tention of  urine.  The  condition  is  serious  on  account  of  the 
grave  danger  of  septic  infection  of  the  clot.  An  attempt  may 
be  made  with  a  large  metal  catheter  to  break  up  the  clot  and 
wash  it  out ;  or  a  lithotrite  may  be  used,  and  an  evacuating 
cannula.  Very  little  time  should  be  spent  in  these  attempts, 
and  the  bladder  should  be  opened  suprapubically  without  further 
delay,  the  masses  of  clot  removed,  and  a  large  rubber  drain 
placed  in  the  bladder.  Treatment  of  the  growth  or  other  cause 
of  bleeding  will  have  to  be  postponed  until  a  more  convenient  time. 

3.  The  distended  atonic  bladder  of  spinal  disease. — This  should 
be  relieved  by  catheter  with  the  same  precautions  as  are  adopted 
in  enlarged  prostate.  The  introduction  to  regular  catheterization 
is  similar  to  that  in  enlarged  prostate. 

4.  Retention  from  reflex  spasm  in  disease  of  or  after  operation 
on  the  rectum,  anus,  testicles,  etc.,  and  hysterical  retention. — In 
operation  cases  the  catheter  is  passed  without  delay,  to  avoid 
distress.  In  other  cases  hot  baths  and  other  means  of  relieving 
spasm,  such  as  are  used  in  retention  due  to  acute  inflammation, 
should  be  tried  before  resorting  to  the  catheter.  A  metal  catheter 
is  the  best  form  of  instrument  in  these  cases.  After  relief  of  the 
retention  the  cause  of  the  spasm  should  be  treated. 

5.  Retention  with  enlarged  prostate. — The  diagnosis  is  made  by 
the  history  of  the  case,  by  the  age  at  which  the  symptoms  com- 
menced, and  by  rectal  examination.  The  preliminary  measures 
which  are  detailed  above  may  be  tried,  but  recourse  to  the 
catheter  will  nearly  always  be  necessary.  Three  points  must  be 
insisted  upon :  (i)  The  most  rigid  asepsis  ;  (ii)  the  delicate 
handling  of  instruments ;  and  (iii)  all  the  urine  of  the  over-dis- 
tended bladder  must  not  be  withdrawn  at  once,  or  it  must  be 
drawn  off  very  slowly. 

The  catheters,  whether  gum-elastic  or  metal,  must  be  boiled, 
the  hands  carefully  cleansed,  the  penis  washed  with  antiseptic, 


XXVIII]  RETENTION   OF   URINE  389 

and  the  uretlnu  with  sohition  of  oxycyanide  of  niercuiy  (1  in 
5,000)  or  permaiifraiiiite  of  j)otash  (1  in  4,000). 

The  instrument  shoukl  be  of  gum-elastic  or  metal.  Coude 
and  bicoude  catheters  are  useful,  and  may  pass  easily.  Where  a 
difficulty  is  encountered  it  may  be  due  to  the  distorted  shape  of 
the  prostatic  urethra,  and  the  greatest  gentleness  should  be  exer- 
cised in  pushing  the  instrument  onwards.  Sometimes  twisting 
it  gently  one  way  or  another  during  the  passage  will  make  it  ride 
over  an  obstacle.  Occasionally  false  passages  have  been  made 
by  previous  instrumentation.  It  may  be  necessary  to  withdraw 
the  instrument  one  or  two  inches,  and  then  push  it  on,  so  as  to 
avoid  being  caught  in  the  cul-de-sac.  When  the  prostate  is  very 
large  the  urethra  is  greatly  elongated,  and  it  is  necessary  to  push 
the  catheter  very  deeply  before  the  urine  begins  to  flow.  Bicoude 
catheters  are  made  specially  long  to  allow  for  the  additional  length 
of  the  urethra  in  these  cases.  A  very  frequent  cause  of  failure  is 
the  use  of  a  catheter  which  is  too  small  or  too  pointed.  The 
obstruction  to  the  catheter  is  not  due  to  narrowing  of  the  canal 
but  to  distortion  of  its  lumen.  A  No.  18  or  No.  20  Fr.  is  the  best 
size  for  routine  use. 

If  the  coude  and  bicoude  catheters  fail,  a  metal  instrument  may 
be  tried.  Special  prostatic  catheters  which  possess  a  very  long 
curve  are  found  in  every  set  of  metal  catheters.  A  method  that 
may  be  adopted  when  other  methods  have  failed  is  to  bend  an 
English  gum-elastic  catheter  containing  its  stilet  into  a  very 
complete  curve  which  commences  by  dropping  down  from  the 
plane  of  the  shaft.  If  this  does  not  pass,  it  has  been  recom- 
mended to  pull  the  stilet  out  while  holding  the  catheter  in  the 
urethra,  so  that  the  beak  of  the  instrument  bores  forwards  and 
enters  the  bladder. 

These  manoeuvres  failing,  it  may  be  necessary  to  puncture 
the  bladder  suprapubically  with  an  aspirator  needle. 

Three  dangers  attend  the  rapid  emptying  of  an  over-dis- 
tended bladder — haemorrhage  from  the  vessels  of  the  bladder  or 
kidney ;  acute  urinary  infection,  either  autogenous  or  introduced 
with  the  catheter ;  and  suppression  of  urine.  In  order  to  avoid 
these  the  following  procedure  is  adopted :  The  patient  is  in  bed 
and  in  a  warm  atmosphere.  Only  10-15  oz.  should  be  dra^ai  off, 
and  an  interval  of  half  an  hour  or  one  hour  should  elapse  before 
a  similar  amount  is  again  mthdrawn,  and  so  on  until  the  bladder 
is  empty,  the  catheter  being  retained  in  the  urethra  meanwhile. 

Another  method  is  to  withdraw  a  pint  of  urine  and  substitute 
half  a  pint  of  warm  boric  solution,  and  repeat  this  at  intervals 
until  only  boric  solution  is  left. 


390  THE   BLADDER  [chap. 

Or,  again,  a  catheter  of  very  small  calibre  is  introduced  and 
the  urine  allowed  to  dribble  slowly  away. 

When  the  bladder  is  empty  a  few  syringefuls  of  silver  nitrate 
solution  (1  in  10,000)  should  be  injected  and  allowed  to  escape. 
The  catheter  should  be  tied  in. 

Stimulants  are  usually  necessary  in  these  cases.  A  mixture 
containing  urotropine  10  gr.,  liquor  strychninee  5  minims,  liquid 
extract  of  ergot  5  minims,  citrate  of  potash  20  gr.,  and  infusion 
of  buchu  1  oz.  should  be  given  every  four  hours. 

After  several  days'  continuous  bladder  drainage,  the  decision 
will  have  to  be  made  whether  "  catheter  life  "  is  to  be  commenced 
or  an  operation  performed. 

6.  Retention  with  stricture. — A  hot  sitz-bath  and  hot  rectal 
injection  followed  by  a  suppository  of  morphia  (^  gr.)  may  be 
tried,  but  recourse  to  instruments  will  in  most  cases  be  necessary. 

The  method  of  passing  instruments  through  a  narrow  stric- 
ture is  described  elsewhere  (p.  631). 

In  cases  where  a  No.  7  or  No.  8  Fr.  bougie  can  be  passed  it 
should  be  withdrawn  and  a  catheter  of  this  size  introduced. 

If  only  a  filiform  bougie  will  pass,  it  should  be  tied  in  place 
with  a  piece  of  silk,  the  ends  of  which  are  carried  along  the  sides 
of  the  penis  and  fixed  by  means  of  strapping.  After  half  an  hour 
the  urine  begins  to  trickle  alongside  the  bougie,  a  few  hours  later 
the  stricture  will  allow  of  a  larger  instrument  being  passed,  and 
eventually  a  catheter  is  introduced. 

A  more  rapid  method  is  to  use  a  special  instrument  consist- 
ing of  a  metal  catheter  with  a  conical  end  which  screws  on  to  a 
filiform  bougie.  The  bougie  acts  as  a  guide,  and  the  catheter  is 
forced  through  the  stricture.  Harrison's  whip  bougies  are  some- 
times useful.  They  consist  of  a  gradually  tapering  gum-elastic 
bougie  20  in.  in  length,  the  end  of  which  is  filiform,  while  the 
shaft  rises  to  the  size  of  18-20  Fr.  These  may  be  made  with  a 
groove  along  one  side,  by  which  the  urine  trickles  away.  Another 
special  instrument  is  a  tunnelled  catheter  which  can  be  threaded 
upon  the  filiform  bougie  and  pushed  through  the  stricture. 

There  is  less  danger  in  completely  emptying  a  distended 
bladder  in  a  case  of  stricture  than  in  enlarged  prostate,  for  the 
age  of  the  patient  is  less,  and  the  kidneys  are  usually  not  so 
extensively  diseased  as  the  result  of  obstruction  and  arterio- 
sclerosis. At  the  same  time  diuretics  and  stimulants  should  be 
administered  to  guard  against  suppression  of  urine. 

If  instrumentation  fail,  the  bladder  should  be  emptied  with 
an  aspirator  needle.  The  most  suitable  point  for  the  puncture 
is  an  inch  above  the  upper  margin  of  the  pubic  symphysis  in  the 


XXVIII]         RETENTION   WITH   STRICTURE  391 

middle  line.  The  percussion  note  should  be  dull.  The  skin  is 
cleansed,  and  incised  with  a  sharp  scalpel,  and  the  aspirator 
needle  introduced.  The  urine  will  flow  from  the  cannula  with- 
out a  negative  pressure  being  produced.  The  dangers  connected 
with  aspiration  of  the  bladder  are  puncture  of  the  peritoneum 
with  subsequent  peritonitis,  leaking  of  the  wound  in  the  bladder, 
and  the  formation  of  a  prevesical  abscess,  or  in  more  vimlent 
infectious  a  spreading  pelvic  cellulitis.  There  is  little  risk  of 
wounding  the  peritoneum  when  the  bladder  is  distended  and 
the  percussion  note  dull.  The  aspirating  needle  should  not  be  a 
large  one,  lest  leakage  at  the  point  of  puncture  of  the  bladder 
take  place. 

Usually,  after  a  single  aspiration  an  instrument  can  be  intro- 
duced through  the  stricture  and  tied  in,  but  rarely  the  puncture 
must  be  repeated  several  times.  In  such  a  case  operation  for  the 
relief  of  the  stricture  should  be  performed  as  soon  as  possible. 
The  operation  ^^^ll  take  the  form  of  a  Wheelhouse  operation. 


CHAPTEK  XXIX 
CONGENITAL  MALFORMATIONS 

Development  of  the  bladder  and  urethra. — In  order  to 
explain  malformations  of  the  bladder  and  urethra  it  is  necessary 
to  make  a  brief  note  in  regard  to  the  development  of  this  part 
of  the  urinary  tract. 

The  allantois,  a  hollow  tube  of  hypoderm  with  a  covering  of 
mesoderm,  opens  posteriorly  into  the  hindgut.  A  septum  de- 
velops between  the  allantois  and  the  hindgut,  and  both  come 
to  open  into  a  common  cloaca.  As  the  septum  descends,  the 
cloaca  is  divided  into  a  dorsal  or  anal  portion  and  a  genital  or 
urogenital  sinus.  The  sinus  and  allantois  form  a  tube  on  which 
a  dilatation  (the  bladder)  appears  at  the  second  month,  implicating 
the  portion  belonging  to  the  sinus,  and  probably  also  a  part  of  the 
allantois.  The  remainder  of  the  allantois  is  obliterated  and 
forms  the  urachus.  The  Wolffian  ducts,  the  progenitors  of  the 
vasa  deferentia  and  ejaculatory  ducts  in  the  male,  open  into  the 
sinus  by  a  common  opening  with  the  ureters.  Further  growth 
leads  to  separation  of  these  ducts  from  the  ureters,  so  that  the 
ureters  come  to  open  into  the  bladder  dilatation  and  the  Wolffian 
ducts  into  the  urogenital  sinus.  The  sinus  eventually  comes  to 
form  the  prostatic  and  membranous  urethra  in  the  male,  and 
the  whole  of  the  urethra  and  the  vestibule  in  the  female.  The 
Wolffian  ducts  open  on  an  eminence,  and  between  them  the  fused 
Miillerian  ducts  end.  This  eminence  persists  as  the  crista  urethrse  in 
the  male,  and  when  the  ureters  become  separated  by  elongation  of 
this  portion  and  diverge  from  each  other  the  upper  part  forms  the 
trigone  of  the  bladder.  It  can  thus  be  realized  how  malposition 
of  the  ureteric  orifice  in  the  prostatic  urethra  or  into  the  seminal 
vesicle  may  take  place  by  persistence  of  the  foetal  condition. 

The  cloaca  at  first  extends  from  the  umbilicus  to  the  root  of 
the  tail,  and  is  covered  by  the  cloacal  membrane.  On  either 
side  the  mesoderm  encroaches  upon  this  until  it  meets  in  the 
median  line  from  the  umbilicus  backwards  for  some  distance. 
This  union  ends  behind  in  an  eminence,  the  genital  tubercle,  which 
lies  at  the  anterior  end  of  the  reduced  cloaca,  and  is  at  first  con- 

392 


CHAP.  XXIX]     DEVELOPMENT   OF   URETHRA  393 

tained  in  it.  On  each  side  of  the  cloaca  ridges  appear,  forming  the 
outer  genital  folds,  which  eventually  form  the  labia  majora  or  the 
scrotum.  A  groove  forms  on  the  under  or  posterior  surface  of 
the  genital  tubercle,  the  urethral  groove.  The  edges  of  this  groove 
constitute  the  inner  genital  folds,  which  form  the  labia  minora  in 
the  female,  and  in  the  male  unite  to  form  the  floor  of  the  bulbous 
and  penile  urethra.  At  the  surface  the  septum  which  divides  the 
cloaca  into  anal  and  urogenital  segments  forms  the  perineum. 

In  the  female  the  urogenital  sinus  becomes  the  vestibule,  the 
inner  genital  folds  form  the  labia  minora,  and  the  outer  genital 
folds  the  labia  majora.     The  genital  tubercle  forms  the  clitoris. 

In  the  male  the  inner  genital  folds  unite  from  behind  forwards 
in  the  middle  line,  and  as  the  penis  becomes  extruded  from  the 
cloaca  this  union  passes  forwards  so  as  to  close  in  the  groove  on 
the  under  surface  of  the  genital  tubercle,  and  the  bulbous  and  penile 
parts  of  the  urethra  are  formed.  The  orifice  of  the  urethra  is 
now  on  the  under  surface  of  the  penis  at  the  base  of  the  glans 
penis,  and  this  opening  represents  the  orifice  of  the  urogenital 
sinus.  The  end  of  the  tubercle  forms  the  glans  penis,  and  the 
portion  of  the  urethra  which  traverses  this  is  formed  separately  by 
folding  over  the  edges  -of  the  groove  on  its  mider  surface.  Berry 
Hart  believes  that  this  part  of  the  urethra  is  formed  by  the 
ingrowth  and  hollowing  of  a  rod  of  epithelium,  but  the  above 
description  is  generally  accepted. 

The  last  part  to  be  completed  is  the  junction  of  this  part  of 
the  urethra  with  the  rest  of  the  penile  urethra.  It  is  interesting 
to  note  how  closely  the  various  forms  of  hypospadias  correspond 
to  the  stages  of  development  of  the  urethra.  The  prepuce  is 
formed  by  an  ingrowth  of  solid  ectoderm.  The  outer  genital  folds 
unite  in  the  middle  line  to  form  the  scrotum,  and  the  median  scrotal 
raphe  represents  their  line  of  union. 

ABSENCE  OF  THE  BLADDER 

The  bladder  is  rarely  absent,  except  in  cases  where  there  are 
extensive  congenital  deformities  of  the  pelvic  organs  which  are 
incompatible  with  life.  A  few  cases  have  been  observed  clinically 
(Fleury,  Benninger)  in  which  the  bladder  was  the  only  organ 
afiected,  and  the  ureters  opened  into  the  urethra.  The  bladder 
was  represented  by  a  small  pocket,  the  size  of  a  bean.  Incon- 
tinence of  urine  is  present,  and  ascending  pyelonephritis  occurs. 

CONGENITAL  DILATATION 

The  dilated  bladder  may  be  a  cause  of  difficulty  in  labour. 
Urethral  obstruction  may  be  present  in  the  form  of  atresia,  folds 


394  THE   BLADDER  [chap. 

or  valves  or  cysts  of  the  urethra,  or  torsion  of  the  penis.  Rarely, 
no  obstruction  of  the  urethra  is  present,  and  the  condition  is 
probably  due  to  changes  in  the  sympathetic  ganglia.  The  ureters 
are  usually  dilated,  and  the  kidneys  greatly  distended,  and  there 
is  also  congenital  dilatation  of  the  colon.  The  bladder  may  be 
greatly  thickened  and  hypertrophied  in  congenital  hydronephrosis. 


FISTULA  OF  THE  UEACHUS 

When  the  whole  of  the  lumen  of  the  allantois  remains  patent 
a  urachal  fistula  results.  Urethral  obstruction  is  frequently  the 
cause  of  the  persistence  of  the  lumen.  In  these  cases  the  bladder 
is  often  dilated.  In  infants  a  membrane  or  fold  in  the  urethra 
may  cause  the  condition.  The  allantois  may  close  and  the  fistula 
appear  in  adult  life,  when  it  may  be  due  to  urethral  stricture  or 
enlargement  of  the  prostate.  In  some  cases  no  urethral  obstruc- 
tion is  present  and  it  is  supposed  that  a  temporary  obstruction 
has  been  present  in  foetal  life  and  has  disappeared. 

The  fistula  opens  at  the  umbilicus,  sometimes  on  a  small, 
raspberry-like  tumour.  It  is  usually  narrow,  but  it  may  admit  a 
filiform  bougie.  The  opening  into  the  bladder  may  be  minute, 
or  it  may  be  so  large  as  to  admit  three  fingers  (Marshall).  Urine 
escapes  from  the  opening  during  micturition  or  constantly.  There 
may  be  a  leakage  in  drops,  or  a  tiny  jet  may  escape.  Any  doubt 
as  to  the  nature  of  the  fistula  is  settled  by  examination  of  the 
fluid  for  urea,  or  by  injecting  methylene  blue  into  the  bladder, 
when  the  fluid  discharged  from  the  fistula  becomes  coloured.  A 
malignant  growth  may  develop  at  the  umbilical  orifice.  A  portion 
of  the  urachus  at  the  vesical  end  may  remain  unobliterated  and 
form  a  diverticulum  at  the  apex  of  the  bladder.  Dykes  reports 
a  case  in  which  there  was  a  calculus  in  such  a  diverticulum. 

Pressure  and  cauterization  are  uncertain  methods  of  treat- 
ment. The  track  of  the  fistula  should  be  excised  from  the 
umbilicus  to  the  bladder,  and  the  bladder  wall  repaired.  It  may 
be  necessary  to  open  the  peritoneum,  but  this  should  be  avoided 
if  possible. 

URACHAL  CYSTS 

The  majority  of  these  cysts  are  found  in  women  in  adult  life. 
They  vary  in  size  from  a  chestnut  to  large  cysts  occupying  a  large 
part  of  the  abdominal  cavity  and  containing  many  pints  of  serous 
or  blood-stained  fluid. 

The  cysts  are  thin-walled  and  lined  with  mucous  membrane, 
and  the   wall   contains  non-striped  muscle.     In  large  cysts  the 


XXIX]  DOUBLE    BLADDER  395 

wall  is  thin  and  the  layers  are  indistinguishable.  There  may  be 
a  fine  communication  with  the  bladder  or  with  the  exterior  at  the 
umbilicus.  Frequent  micturition  or  incontinence  of  urine  may  be 
present.  Infection  of  the  cyst  has  been  observed.  In  small  cysts 
the  position,  and  sometimes  adhesions  to  the  umbilicus,  are  relied 
upon  for  diagnosis.     In  large  cysts  diagnosis  may  be  impossible. 

Excision  of  the  cyst  is  the  proper  treatment,  but  in  some  cases 
dense  adhesions  have  prevented  this  being  done  and  the  cyst 
was  drained. 

MEMBRANES  AND  DOUBLE  BLADDER 

There  may  be  incomplete  division  of  the  bladder  cavity  with 
a  membrane  or  fold.  This  may  be  longitudinal  and  sickle-shaped, 
or  transverse,  and  the  bladder  is  partly  divided  into  two  unequal 
compartments,  an  hour-glass  bladder  being  formed.  Cathelin  and 
Sempe  collected  32  cases  of  double  bladder.  The  bladder  is  divided 
by  a  vertical  septum  into  two  compartments  which  open  into 
the  urethra.  Abnormalities  in  the  ureters  or  other  congenital 
malformations  are  sometimes  present. 

Von  Frisch  describes  a  case  of  double  bladder  in  a  man  of 
34  years.  On  cystoscopy  there  was  a  high  septum  in  the  middle 
line  with  transverse  folds  and  covered  with  reddened  oedematous 
mucous  membrane.  The  patient  had  complained  since  childhood 
of  delayed  and  difficult  micturition,  and  eventually  suffered  from 
complete  retention.  The  double  bladder  was  demonstrated  by 
the  X-rays  after  collargol  injection.  Primrose  records  a  case  of 
a  man  aged  50  with  the  following  malformations,  viz.  patent  peri- 
cardium, solitary  kidney,  and  septum  in  the  urinary  bladder.  The 
septum  was  incomplete  and  formed  two  partly  separated  com- 
partments, into  one  of  which  the  ureter  opened. 

LITERATURE 

Cathelin  ct  Sempe,  Ann.  d.  Mai.  d.  Org.  Gen.-  Vrin.,  1903,  p.  339. 

Delbet,   Ann.  d.  Med.  d.   Org.   Gen.-  Urin.,  1907,  p.  641. 

Doran,  Lancet,  May  8,  1909. 

Dykes,  Lancet,  1910,  i.  .566. 

Fortescue-Brickdale,  Repf.  Soc.  Dis.  Child.,  1904,  p.  94. 

von  Frisch,   Verhandl.  d.  deuts.  Gesell.  f.   Urol,  III.  Kongress,  1912. 

Hart,  Berry,  Journ.  Anat.  and  Phys.,  1903,  p.  330. 

Holt,   Diseases  of   Injancy  and  Childhood. 

Marshall,   Journ.   Obstet.  and  Gyn.,  1907. 

Pommer,  Wien.  kiin.  Woch.,  1904,  Bd-  xvii. 

Primrose,  Glasg.  Med.  Journ.,  Sept.,  1909. 

Schlagenhaufer,  Wien.  kiin.  Woch.,  1896. 

Schytzer,  Arch.  /.  Gyn.,  Bd.  xliii. 

Vaughan,  Trans.  Amer.  Surg.  Assoc,  1905. 

Weiser,  Ann.  Stirg.,  1906,  p.  529. 

White,  Hale,  Guy's  Hosp.  Repts.,  Iv.  17. 


396  THE   BLADDER  [chap. 

EXTKOVERSION  OF   THE   BLADDER  (ECTOPIA  VESICAE) 

There  is  congenital  absence  of  the  anterior  wall  of  the  bladder, 
so  that  the  mucous  membrane  is  exposed  and  the  urine  is  dis- 
charged on  the  surface.  The  condition  is  rare,  and  male  infants 
are  more  often  affected  than  female. 

Hoenow  found  that  one-quarter  of  the  cases  were  female, 
two-thirds  male,  and  in  the  rest  the  sex  was  uncertain.  Wood 
found  that  only  2  out  of  20  cases  were  females.  The  condition 
appears  at  birth  as  a  dark-red  swelling  the  size  of  a  plum  at  the 
lower  part  of  the  abdomen.  It  is  pear-shaped  with  the  narrow 
end  downwards.  The  eversion  of  the  bladder  wall  is  due  to  the 
intra-abdominal  pressure.  The  upper,  broader  part  of  the  mucous 
membrane  is  folded,  irregular,  and  excoriated,  bleeding  readily 
when  touched,  while  the  lower  part,  which  is  somewhat  triangular 
in  shape  and  corresponds  to  the  trigone,  is  smooth  and  partly 
hidden.  At  the  margin  of  the  mucous  membrane  there  is  a  zone 
of  scar  tissue  which  forms  a  rigid  border  at  the  upper  margin, 
the  "  hypogastric  fold,"  and  from  the  skin  there  are  irregular 
ingrowths  of  epithelium  into  the  mucosa.  The  epithelium  of  the 
mucous  membrane  is  transitional  in  character  with  islands  of 
squamous  epithelium  near  the  cutaneous  margin.  Columnar 
epithelium  is  frequently  observed. 

The  umbilicus  may  be  normal  or  displaced  downwards  and 
containing  a  hernial  sac  ;  it  is  separated  from  the  extroverted 
bladder  by  healthy  skin,  or  the  bladder  may  fill  the  entire  space 
from  the  umbilicus  to  the  root  of  the  penis. 

On  raising  the  prominent  swelling  a  moister  area  of  mucous 
membrane  is  seen,  with  two  nipples  on  which  the  ureters  open. 
These  are  closer  together  than  in  the  normal  condition,  and  the 
trigone  is  undeveloped.  The  ureters  are  frequently  dilated.  The 
muscular  wall  of  the  ectopic  bladder  is  thicker  than  that  of  the 
normal  bladder.  The  penis  is  a  tubercle  1-1^  in.  long,  \vith  un- 
developed corpora  cavernosa  and  glans.  Along  the  dorsum  there 
runs  a  median  groove  which  represents  the  urethra  (epispadias). 
At  the  base  of  the  penis  in  a  small  pocket  are  the  sinus  pocularis 
and  ejaculatory  ducts.  The  foreskin  is  well  developed  in  the  form 
of  an  apron.  The  scrotum  is  split  or  rudimentary,  and  rarely  con- 
tains the  testicles,  which  are  usually  fomid  in  the  inguinal  canals. 
The  prostate  is  absent  or  rudimentary.  The  pubic  bones  do  not 
unite  in  the  middle  line,  and  are  sometimes  separated  as  much 
as  3  in.  or  more  ;  a  fibrous  band  has  been  stated  to  pass  across 
the  middle  line,  uniting  the  pubic  bones,  but  this  is  now  disputed. 
The  ureters,  owing  to  the  absence  of  the  bladder  from  the  abdominal 


XXIX]  EXTROVERSION   OF  BLADDER  397 

cavity,  have  a  longer  course  than  normal ;  they  descend  into  the 
deep  pocket  between  the  rectum  and  the  bladder,  and  then  ascend 
to  the  bladder.  Associated  deformities,  such  as  harelip,  cleft 
palate,  and  spina  bifida,  are  sometimes  observed.  The  perineal 
muscles  may  be  defective  and  the  anal  sphincter  ill  developed 
— an  important  point  when  the  operation  of  transplantation  of 
the  ureters  into  the  rectum  is  proposed. 

The  condition  described  above  is  the  most  common  form,  but 
other  less  extensive  lesions  are  occasionally  found.  There  may 
be  scarring  of  the  suprapubic  region  without  separation  of  the 
pubic  bones  or  defect  of  the  abdominal  wall  or  bladder.  In  other 
cases  the  pubic  bones  are  separated,  and  there  is  scarring  of  the 
skin.  In  a  still  more  advanced  form  there  is  a  defect  of  the 
abdominal  wall  with  exposure  and  thinning,  but  without  perfora- 
tion of  the  bladder  wall.  In  a  further  stage  a  fistula  of  the  bladder 
above  or  below  the  pubic  symphysis  exists.  Finally,  a  more 
extensive  congenital  defect  than  the  common  variety  of  extro- 
version described  above  may  rarely  be  observed :  in  this  the 
bowel  below  the  lower  ileum  or  the  caecum  is  wanting,  and  the 
ileum  opens  behind  the  ureters  in  a  common  cloaca. 

Etiology. — The  cause  of  the  malformation  is  unknown.  Two 
theories  have  been  advanced  to  explain  the  anatomical  conditions 
present.  According  to  one,  there  is  an  arrest  at  an  early  period 
of  development.  It  has  been  pointed  out,  however,  that  at  no 
period  of  development  is  the  bladder  open  on  its  anterior  wall. 
This,  with  the  frequent  coincidence  of  dilated  ureters  and  kidneys, 
has  led  to  the  second  suggestion,  that  there  is  an  intra-uterine 
rupture  of  the  bladder  following  obstruction  and  back  pressure. 

More  recent  work  on  embryology  shows  that  the  cloaca  extends 
at  first  from  the  umbilicus  to  the  base  of  the  tail,  and  that  the 
bladder  is  largely,  if  not  entirely,  formed  from  the  cloaca.  In- 
growths from  mesoderm  on  each  side  reduce  the  size  of  the  cloaca 
from  before  backwards  {see  p.  392).  It  is  evident,  then,  that  a 
failure  of  these  lateral  folds  to  meet  on  each  side  at  the  lower  part 
of  the  abdomen,  and  the  destruction  of  the  cloacal  membrane, 
sufficiently  explain  the  anatomical  conditions  found  in  extro- 
version of  the  bladder. 

There  is  a  difficulty  in  accounting  for  the  presence  of  the 
urethra  as  a  gutter  on  the  dorsum  of  the  penis. 

Symptoms  and  prognosis. — The  thighs  are  widely  separated 
owing  to  the  cleft  symphysis,  and  the  body  is  bent  forwards  so 
as  to  protect  the  sensitive  mucous  surface.  A  peculiar  w^addling 
gait  and  bent  attitude  are  thus  developed. 

The  conditions  of  existence  are  extremelv  miserable.     There  is 


398  THE   BLADDER  [chap. 

the  constant  escape  of  urine,  saturating  the  clothes  and  leading 
to  inflammation  and  excoriation  of  the  skin.  The  child  lives  in 
the  pungent  atmosphere  arising  from  decomposing  urine,  and 
his  life  is  a  burden  to  himself  and  to  those  around  him.  Pro- 
gressive dilatation  of  the  ureters  and  kidneys  occurs.  The  mor- 
tality from  ascending  pyelonephritis  is  very  high,  but  occasionally 
the  patients  attain  adult  life  and  even  old  age. 

A  malignant  growth  may  develop  in  the  exposed  bladder,  and 
may  take  the  form  of  an  adeno-carcinoma. 

Treatment. — Many  operations  have  been  suggested  and 
practised  for  ectopia  vesicae.     The  following  are  the  chief  types  : — 

I.  Formation   of  a   reservoir   in  tlie   body. 

A.  From  the  bladder.  \ 

1.  Closure  of  the  defect  by  osteoplastic  operations. 
'  2.  Closure  of  defect  by  flaps, 

(a)  Autoplastic  methods, 
(i.)    Of  skin, 
(ii.)  Of  intestine. 
(6)  Heteroplastic  methods. 

B.  From  the  rectum. 

1.  By  transplantation  of  the  ureters. 

2.  By  vesico-rectal  fistula, 
c.  From  the  sigmoid  flexure. 

D.  From  the  vagina. 

II.  No   reservoir  formed   in  tlie   body. 

1.  Implantation  of  the  ureters. 

(a)  In  urethra.  * 

(b)  In  skin. 

2.  Nephrostomy. 

A  few  of  the  more  important  of  these  operations  will  be 
described. 

Trendelenburg's  operation  (osteoplastic  operation). — This 
consists  in  opening  the  sacro-iliac  synchondrosis,  which  allows  of 
the  approximation  of  the  separated  pubic  bones  and  subsequent 
closing  of  the  defect  in  the  bladder  wall. 

The  patient  is  placed  in  the  prone  position,  and  a  longitudinal 
incision  made  over  one  sacro-iliac  synchondrosis.  Its  posterior 
ligaments  are  cut  through  and  lateral  pressure  is  applied  to  the 
iliac  bones,  so  that  the  pubic  bone  on  the  operated  side  swings 
towards  the  middle  line.  A  similar  operation  is  performed  on 
the  opposite  side.  The  patient  is  placed  on  a  special  couch.  Round 
the  pelvis  is  passed  a  leather  girdle,  the  ends  of  which  cross  in 
front  and  are  attached  to  cords  and  weights  acting  over  pulleys 
on  each  side.     The  pelvic  bones  are  fixed  in  position  for  some 


XXIX]       OPERATIONS   FOR  EXTROVERSION         399 

weeks.  Three  or  four  moiiths  later  an  attempt  to  close  the 
bladder  is  made  by  separating  the  bladder  wall  and  uniting  it, 
and  bringing  the  component  parts  of  the  abdominal  wall  together 
in  front  of  it.  A  later  attempt  may  be  made  to  reconstruct  the 
urethra. 

Results. — Katz  collected  23  cases,  with  a  mortality  of  21-7 
per  cent.  Improvement  in  rectal  incontinence  has  been  noted 
after  these  operations,  and  three  patients  were  stated  to  have 
gained  control  of  the  urine.  This  must  be  exceptional,  how- 
ever, for  no  provision  is  made  for  sphincteric  control,  and  an 
apparatus  must  be  worn  in  almost  all  cases.  The  opened  syn- 
chondrosis fills  with  clot  and  granulation  tissue,  and  fibrous  tissue 
is  formed  which  contracts  and  drags  the  bones  into  their  original 
position.  Wiring  the  pubic  bones  together  does  not  prevent  this, 
for  the  wire  cuts  through  the  cartilage.  There  is  some  danger  of 
injuring  the  sacral  nerves  and  causing  paralysis  of  the  rectal 
sphincters. 

Wood's  operation  (autoplastic  skin  method). — The  defect 
is  closed  by  skin  flaps  (Fig.  114),  and  the  operation  should  be  done 
about  the  age  of  4  or  5  years.  Several  operations  are  usually 
required,  and  they  should  be  completed  before  puberty,  when 
hairs  grow  upon  the  skin  flap  and  erections  of  the  penis  interfere 
with  the  success  of  the  operation.  If  puberty  be  already  passed 
some  method  should  be  adopted  to  remove  the  pubic  hairs.  Three 
flaps  are  used — a  median  superior  flap  from  the  abdominal  wall 
above  the  bladder,  broad  above  and  narrow  below,  which  is  turned 
down  over  the  defect  skin  inwards ;  and  two  lateral  flaps  from 
the  abdominal  wall  on  each  side,  which  remain  attached  at  their 
lower  ends,  are  swung  inwards  to  meet  in  the  middle  line,  and 
are  stitched  in  this  position  with  the  skin  outwards.  The  trefoil 
surface  thus  laid  bare  is  either  covered  at  once  with  skin  grafts 
or  allowed  to  granulate  and  grafted  later.  The  objections  to  this 
method  are  that  there  is  no  control  and  a  urinal  must  be  worn, 
and  phosphatic  deposit  takes  place  on  the  skin  surface  which 
forms  the  anterior  wall  of  the  bladder. 

Segond's  operation. — The  bladder  is  dissected  from  the 
abdominal  wall  and  turned  downwards  so  that  the  upper  portion 
forms  a  roof  for  the  urethra.  The  ample  prepuce  is  now  unfolded 
so  that  the  upper  surface  is  raw,  and  this  is  reflected  backwards 
on  the  surface  of  the  bladder  flap,  a  hole  being  made  through 
which  the  penis  projects. 

implantation  of  the  ureters  into  the  rectum.  —  The 
dangers  of  implantation  of  the  ureters  into  the  bowel  are  slough- 
ing of  the  womid  and  ascending  pyelonephritis. 


400 


THE  BLADDER 


[chap. 


Fowler  endeavoured  to  protect  the  implanted  ureters  from 
contact  with  the  faeces.  He  cut  the  ureters  obliquely  and  formed 
a  flap  valve  of  mucous  membrane  from  the  anterior  wall  of  the 
rectum.  To  the  under  surface  of  this  he  attached  the  cut  ends 
of  the  ureters  in  the  hope  that  the  descending  faeces  would  press 
upon  the  valve  and  close  the  ureteric  orifices. 

Gersuny  made  an  artificial  anus  at  the  sigmoid  flexure  and 


'^■nf^^^^^'^^'^^'^^ 


Fig.  114. — Wood's  operation  for  extroversion  ot  bladder. 

A,  B,  C,  Raw  surface  left  after  cutting  skin  flaps.     A',  Central  flap  turned  downwards  (dotted 

line)  with  skin  surface  inwards.      B',  C,  Lateral  flaps    swung  inwards  and    stitched  across 

back  of  A'.     D   Covering  for  urethral  gutter  formed  from  foreskin. 

closed  the  upper  end  of  the  rectum.  He  then  transplanted  the 
ureters  into  the  rectum. 

Peters  introduced  catheters  into  the  ureters,  which  he  dis- 
sected from  the  wall  of  the  bladder,  leaving  a  collar  of  bladder 
mucous  membrane  round  each.  The  catheters  and  ureters  were 
passed  through  two  small  openings  in  the  anterior  rectal  wall, 
each  ureter  projecting  about  3  cm.  into  the  cavity.  The  catheters 
were  removed  after  three  days. 

Soubottine's    operation    (Fig.    115). — The  coccyx  is    excised 


XXIX]      OPERATIONS   FOR   EXTROVERSION         401 

and  the  posterior  rectal  wall  slit  up  longitudinally,  cutting  through 
the  anal  sphincter.  A  fistula  is  now  made  between  the  rectum 
and  the  bladder.  A  horseshoe  incision  is  made  with  the  con- 
vexity upwards  round  the  recto-vesical  fistula,  including  one- 
third  of  the  rectal  wall,  the  limbs  of  the  horseshoe  passing  down 
to  the  skin  at  the  anus.  The  edges  of  the  portion  of  rectal  wall 
included  within  this  horseshoe  are  now  united,  and  a  reservoir 
formed.     Finally,  the  rectal  wall  is  united  over  this  and  the  pos- 


Flg.   115. — Soubottine's  operation  for  extroversion  of  bladder. 

The  posterior  wall  of  the  rectum  has  been  slit,  a  vesico-rectal  fistula  formed,  the  incision  for 
the  rectal  pouch  made,  and  the  stitches  introduced. 

terior  rectal  wall  repaired.  The  neck  of  this  urinary  receptacle 
is  within  the  grasp  of  the  anal  sphincter. 

The  suprapubic  gap  in  the  bladder  wall  is  closed  by  a  skin- 
flap  operation.  One  patient  operated  on  in  this  manner  obtained 
complete  continence  and  held  urine  for  four  hours. 

Maydl's  operation  (Figs.  116,  117). —  The  trigone  of  the 
bladder,  together  with  the  ureteric  orifices,  is  transplanted  into 
the  sigmoid  flexure  of  the  colon.     A  catheter  is  introduced  into 


402 


THE  BLADDER 


[chap. 


each  ureter,  and  the  bladder  separated  completely  from  the 
abdominal  wall.  The  bladder  wall  is  cut  away,  leaving  an  oval 
area  on  which  the  ureters  open.  Care  is  taken  not  to  injure  the 
vesical  arteries.  A  knuckle  of  sigmoid  flexure  is  isolated  and 
incised  longitudinally,  and  the  bladder  base  is  implanted  into  it 
and  carefully  sutured.     Maydl  fixes  the  bowel  in  the  abdominal 


Fig.  116. — Maydl's  operation  for  extroversion  of  bladder. 

Stage  1.    The  bladder  is  being  separated  from  the  abdominal  wall.     Catheters  are  lying  in  the 
ureters,  and  the   dotted  line  shows   the  portion  of  the  bladder  base  that  will  be  transplanted 

into  the  intestine. 

wound  on  account  of  the  danger  of  peritonitis  from  the  line  of 
suture  giving  way. 

This  method  has  proved  the  most  successful  of  the  bowel- 
implantation  methods  owing  to  the  retention  of  the  sphincter 
action  of  the  lower  end  of  the  ureters. 

Moynihan  dissected  up  the  whole  bladder  and  implanted  it  into 
the  colon.     Kocher  brings  out  a  knuckle  of  sigmoid,  implants  the 


XXIX]       OPERATIONS  FOR   EXTROVERSION 


403 


bladder  base  at  the  apex  of  the  loop,  and  short-circuits  the  bowel 
at  the  base  of  the  loop. 

The  immediate  mortality  of  Maydl's  operation  varies  from 
5-5  per  cent.  (Josseraud,  18  cases)  to  26-7  per  cent.  (Katz,  57 
cases).  In  Petersen's  collection  31  patients  recovered  from  the 
operation ;    of  these  2   died  of   pyelitis   within  a  year.     In  the 


Fig.  117. — Maydl's  operation. 

Stage  2.  The  portion  of  the  bladder  base  surrounding  the  ureteric  orifices  is  implanted  into 
the  sigmoid  flexure  of  the  colon.     The  double  row  of  stitching  is  seen. 

-other  cases  the  control  of  the  anal  sphincter  was  good  in  every 
case  but  one.  In  6  cases  the  operation  was  followed  by  fistula, 
which  in  every  instance  subsequently  closed.  Before  embarking 
on  this  most  satisfactory  operation,  the  surgeon  should  ascertain  if 
the  anal  sphincter  retains  fluid  motions. 

In  Sonnenberg's  operation  the  bladder  is  excised  and  the 
ureters  implanted  in  the  urethra.  This  allows  of  the  fitting  of 
.a  receptacle  which  will  collect  the  urine. 


404  THE   BLADDER  [chap,  xxix 

LITERATURE 

Connell,  Journ.  Amer.  Med.  Assoc,  1901,  p.  637. 

Fowler,   Amer.   Journ.  Med.  Sci.,  1898,  p.  270. 

Frank,  Ann.  Surg.,  1903,  p.  291. 

Gersuny,  Wien.  Min.  Woch.,  1898,  No.  43. 

Hager,  3Iunch.  med.  Woch.,  1910,  p.  2301. 

Hoenow,  Inaugural  Dissertation,  Berlin,  1884. 

Josseraud,  Gaz.   Hebdom.  de  Med.  et  de  Chir.,  1895,  p.  117. 

Katz,  These  de  Paris,  1903. 

Keith,  Brit.  Med.  Journ.,  1908,  ii.  1858. 

Lendon,  Brit.  Med.  Journ.,  1906,  i.  961. 

Maydl,  Wien.  med.  Woch.,  1894,  1896,  1899. 

Moynihan,   Ann.  Surg.,  1906,  p.  237. 

Newland,  Brit.  Med.  Journ.,  1906,  p.  964. 

Peters,  Brit.  Med.  Journ.,  June  22,  1901  ;    1902,  ii.  1538. 

Petersen,  Med.   News,  Aug.  11,  1911. 

Segond,   Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1890,  p.  193. 

Soubottine,  Wratsch,  1901. 

Trendelenburg,  Gentralhl.  f.   Chir.,  Dec,  1885  ;  Ann.  Surg.,  1906,  p.  281. 

Watson,  Ann.  Surg.,  1905,  p.  813. 

Wood,  Brit.  Med.   Journ.,  1880. 

Zuckerkandl,  Handbuch  der  Urologie  (von  Frisch  und  Zuckerkandl),  1905. 


CHAPTER  XXX 
CYSTOCELE— PROLAPSE-DIVERTICULA 

HERNIA  OF   THE  BLADDER  (CYSTOCELE) 

Hernia  of  the  bladder  is  comparatively  rare.  Moynihan  found 
23  bladder  hernias  in  2,543  collected  cases  of  hernia  operations, 
or  about  1  per  cent.  It  is  much  more  frequent  in  men  than  in 
women  (115  in  144 — Alessandri),  and  is  most  common  in  advanced 
life,  although  cases  occurring  in  children  have  been  described. 
The  average  age  in  males  is  51  and  in  females  44  (Moynihan). 
The  great  majority  of  bladder  hernias  are  inguinal ;  femoral  are 
much  less  common,  but  are  more  frequent  in  women  than  in  men 
(27  to  2).  A  few  rare  records  of  obturator,  sciatic,  and  perineal 
hernia  and  of  hernia  in  the  linea  alba  exist. 

Etiology. — A  thin-walled  bladder  placed  in  close  relation  to 
a  weak  inguinal  or  femoral  ring  is  either  drawn  through  or  forced 
into  it.     The  following  are  recognized  causes : — 

1.  Urethral  obstruction  with  distension  of  the  bladder  (stric- 
ture, enlarged  prostate,  pelvic  growths).  The  wall  is  usually 
thinned  and  its  muscular  power  weak,  but  in  a  few  cases  there 
has  been  hypertrophy  with  thickening  of  the  wall. 

2.  Weakness  of  the  abdominal  wall,  such  as  is  found  in  old 
age  and  other  contributory  causes  of  hernia. 

3.  Intermittent  increase  in  intra-abdominal  pressure,  which 
may  be  caused  by  coughing,  straining  to  pass  water,  etc. 

4.  Traction  upon  the  bladder  drawing  it  through  the  weak 
abdominal  wall.  This  may  be  the  traction  (a)  of  an  extraperi- 
toneal lipoma,  (b)  of  extraperitoneal  fat  on  the  sac  of  a  hernia 
upon  adherent  perivesical  fat,  (c)  of  the  peritoneum  of  a  large 
hernial  sac  on  the  peritoneum  covering  the  bladder,  or  {d)  adhesions 
between  the  omentum  or  intestine  and  the  intraperitoneal  por- 
tion-of  the  bladder  dragging  this  into  the  hernial  sac.  A  number 
of  these  factors  unite  to  produce  a  bladder  hernia.  Bland-Sutton 
relates  a  case  in  which  there  was  an  enlarged  prostate  and  dis- 
tended thinned  bladder  and  the  inguinal  canal  contained  a  fibro- 
fatty  tumour  of  the  spermatic  cord,  a  fat-covered  "  diverticulum  " 
of  the  bladder,  and  a  hernial  sac  in  which  there  was  omentum. 

405 


406 


THE  BLADDER 


[chap. 


Varieties. — Three  varieties  are  found   (Fig.  118)  : 

1.  Paraperitoneal,  in  which  a  sac  of  peritoneum  is  present, 
and  adherent  to  this  is  the  bladder.  The  large  majority  of  vesical 
hernias  are  of  this  variety.  Usually  only  a  small  portion  of  the 
bladder  is  involved,  but  a  large  part  of  the  ^dscus,  together  with 
the  ureters  and  even  the  prostate,  has  been  foimd  in  the  hernia. 

2.  Eoitraperitoneal,  in  which  there  is  prolapse  of  the  bladder 
without  a  hernial  sac  of  peritoneum. 

3.  Intraperitoneal,  in  which  the  peritoneum-covered  portion  of 
the  bladder  is  drawn  into  a  hernial  sac  together  with  bowel  and 
omentum. 

Intraperitoneal  cystocele  lies  outside  the  deep  epigastric 
artery  (obhque  hernia).  Extraperitoneal  cystocele  lies  internally 
to  this  vessel  (direct  hernia),  while  paraperitoneal  cystocele  may 


PBRITOHEUH 

BLADDER. 

-PERITONEI 


Fig.  118.— Hernia  of  bladder. 

A,  Paraperitoneal  variety.     B  Extraperitoneal  variety.     C,  Intraperitoneal  variety. 

be  oblique  or  direct.  The  communication  between  the  prolapsed 
portion  of  the  bladder  and  the  main  cavity  may  be  temporarily 
narrowed,  but  there  is  never  a  diverticulum  in  the  true  sense, 
and  after  the  prolapsed  portion  is  returned  to  the  pelvis  no  change 
can  be  found  with  the  cystoscope.  Hernia  of  the  bladder  occurs 
most  frequently  in  an  inguinal  hernia  which  has  recurred  after 
operation.  One  of  Gifford's  two  cases  of  extraperitoneal  bladder 
hernia  was  that  of  a  child  aged  5,  on  whom  a  previous  operation 
had  been  performed.  Cystitis  may  be  present,  and  a  phosphatic 
stone  has  been  known  to  form  in  the  prolapsed  portion  of  the 
bladder. 

Symptoms. — There  is  an  inguinal  or  femoral  swelling  having 
the  characteristics  of  an  ordinary  hernia.  The  swelling  increases 
in  size  in  the  erect  posture.     It  has  the  following  characteristics : 


XXX]  GYSTOCELE  :    SYMPTOMS  407 

(1)  It  is  irreducible.  (2)  When  the  bladder  is  distended  it  is 
large,  and  when  the  bladder  is  emptied  it  subsides  and  only  an 
indefinite  thickening  is  left,  or  an  ordinary  hernia  may  persist. 

(3)  Pressure    upon   the    swelling    causes    a    desire   to    micturate. 

(4)  Fluctuation  may  be  detected  if  the  hernia  is  large.  (5)  The 
swelling  is  dull  on  percussion. 

Symptoms  pointing  to  implication  of  the  bladder  in  the  hernia 
may  be  present,  but,  as  the  prostate  is  enlarged  or  other  urethral 
obstruction  is  present  in  many  of  these  cases,  the  significance  of 
the  symptoms  may  be  overlooked. 

Micturition  in  two  parts  is  a  common  symptom.  Urine  is 
passed,  and  then  after  a  pause  a  second  quantity  is  passed,  some- 
times after  pressure  upon  the  hernia  or  by  assuming  some  par- 
ticular position.  There  is  difficulty  in  micturition,  and  some- 
times complete  retention,  and  the  patient  may  only  be  able  to 
pass  water  by  pressing  on  the  swelling  or  in  a  certain  posture. 
Cystitis  may  complicate  the  condition.  Urinary  symptoms  may 
be  completely  absent. 

In  a  case  under  my  care  there  were  no  urinary  symptoms, 
but  only  constant  deep-seated  peMc  pain,  which  was  unrelieved 
by  operation.  Cystoscopy  after  operation  showed  no  abnormahty 
of  the  bladder. 

On  introduction  of  a  catheter  it  may  pass  into  the  hernial 
sac  and  be  felt  through  the  skin.  Injection  of  fluid  into  the 
bladder  distends  the  hernial  swelling.  Strangulation  of  a  bladder 
hernia  has  occurred  in  several  cases.  The  svmptoms  are  those  of 
strangulation  of  an  intestinal  hernia,  but  constipation  is  absent. 
Bladder  symptoms  are  frequently  wanting,  but  there  may  be 
strangury.     Hiccough  is  sometimes  a  prominent  svmptom. 

Diagnosis. — The  diagnosis  is  usually  made  for  the  first  time 
at  operation,  for  there  are  frequently  no  symptoms  to  point  to 
the  presence  of  the  bladder  in  the  hernia.  If  suspicion  of  the 
nature  of  the  swelling  is  aroused,  some  of  the  characteristic  symp- 
toms may  lead  to  a  diagnosis,  and  cystoscopy  will  help. 

The  diagnosis  of  the  condition  is  made  at  operation  on  hernia 
in  67  per  cent,  of  cases,  and  unintentional  wounds  of  the  bladder 
or  inclusion  in  the  ligature  of  the  hernial  sac  seldom  occur  if 
due  care  be  taken  in  clearing  and  inspecting  the  neck  of  the  sac 
in  a  radical  ciu'e  of  hernia.  The  discovery  is  made  when  the  sac 
is  being  freed,  and  the  bladder  in  the  most  frequent  form  of 
vesical  hernia  (paraperitoneal)  is  found  adherent  to  the  median 
aspect  of  the  surface  of  the  sac.  It  is  covered  by  perivesical  fat, 
and  when  this  is  removed  the  muscular  wall,  on  which  veins 
course,  is  exposed.     When  the  perivesical  fat  is  wanting  and  the 


408  THE   BLADDER  [chap. 

bladder  wall  is  thinned  by  distension,  it  may  not  be  possible  to 
recognize  the  organ  until  its  cavity  is  opened.  When  this  has 
occurred  the  nature  of  the  case  is  demonstrated  by  the  escape 
of  urine,  the  appearance  of  the  mucous  membrane,  and  the  free- 
dom with  which  a  probe  passes  behind  the  pubes,  and,  if  necessary, 
the  passage  of  a  metal  instrument  through  the  urethra  into  the 
bladder  can  be  felt  from  the  inguinal  cystotomy  wound. 

When  the  bladder  alone  forms  the  hernia  (extraperitoneal) 
the  same  features  assist  in  the  diagnosis.  If  the  bladder  has 
passed  unnoticed  at  a  hernia  operation,  and  has  been  included 
in  or  pierced  by  a  ligature,  hsematuria  and  strangury  follow  the 
operation,  and  sometimes  the  escape  of  urine  from  the  hernia 
wound.  Fatal  peritonitis  usually  supervenes.  The  significance 
of  these  symptoms  is  frequently  overlooked.  I  have  made  an 
autopsy  on  a  child  who  died  of  peritonitis  following  operation  on 
an  inguinal  hernia.  The  bladder  had  been  mistaken  for  the 
muscles  of  the  abdominal  wall  and  sutured  to  Poupart's  ligament. 
Prognosis. — There  is  danger  that  the  surgeon  may  not  recog- 
nize the  bladder  at  the  operation,  may  puncture  it,  or  include  it 
in  a  ligature,  and  fail  to  appreciate  the  significance  of  the  symp- 
toms which  follow.  If  the  bladder  be  recognized  and  treated  at 
the  operation  the  danger  is  not  great.  Hermes  found  the  mor- 
tality of  hernia  operations  involving  the  bladder  to  be  19-5  per 
cent.  ;  when  the  bladder  was  uninjured  it  was  6-5  per  cent.,  and 
when  it  was  injured  26-5  per  cent. 

Treatment.  —  When  urethral  obstruction  is  present  this 
should  be  removed,  and  in  some  cases  when  the  cystocele  is  intra- 
peritoneal it  may  be  controlled  by  p,  truss.  In  the  great  majority 
of  cases,  however,  the  hernia  is  irreducible  and  an  operation  is 
necessary.  When  the  bladder  is  found  within  the  hernial  sac  it 
is  reduced  with  the  other  contents,  adhesions  to  bowel  or  omentum 
being  first  separated,  and  the  radical  cure  of  the  hernia  carried 
out  in  the  usual  manner.  If  the  prolapsed  bladder  is  recognized 
outside  the  sac  it  should  be  dissected  off  and  returned  to  the 
abdomen  without  being  opened.  If  a  considerable  portion  of  the 
bladder  is  covered  by  peritoneum,  this  may  be  left  adherent  to 
the  bladder  and  excised  from  the  sac.  Great  care  is  necessary  to 
avoid  tearing  the  bladder  wall  during  the  dissection. 

After  radical  cure  of  the  hernia,  care  should  be  taken  to 
remove  urethral  obstruction,  if  such  exists. 

If  the  bladder  be  opened  during  the  operation,  it  should  be 
carefully  dissected  off  the  sac  and  the  opening  closed  by  a  double 
layer  of  catgut  sutures.  The  bladder  is  then  returned  to  the 
pelvis,   the  hernia  operation   completed,   and  a  caijieter  tied  in 


XXX]  PROLAPSE   OF   BLADDER  409 

the  urethra  for  a  week.  Should  any  sign  of  pericystitis  super- 
vene, a  median  suprapubic  incision  should  be  made  and  the 
perivesical  extraperitoneal  space  drained  through  this. 

LITERATURE 

Alessandri,  Ann.  d.  Mai.  d.  Org.   Gin.-  Urin.,  1901. 

Bland-Sutton,  Arch.  Middx.  Hosp.,  1910,  p.   10. 

Brunner,  Deuts.  Zeits.  f.  Chir.,  Bd.  xlvii. 

Curtis,  Brit.  Med.   Journ.,  1903,  ii.  (59. 

Foy,  Brit.  Mid.   Journ.,  1897. 

Hamilton- Whiteford,  Lancet,  1900. 

Hermes,  Deuts.  Zeits.  /.   Chir.,  Bd.  xlv. 

Malcolm,  Trans.  Med:  Soc.  Lond.,  1908,  p.  26. 

Martin,  Deuts.  Zeits.  /.   Chir.,  Bd.  liv. 

Monod  et  Delageniere,  Rec.  de  Chir.,  1889,  p.  701. 

Moynihan,   Brit.  Med.   Journ.,  1900,  i.  503. 

Noall,  Pract.,  1910,  Ixxxiv.  842. 

Zuckerkandl,  Handhuch  der  Urologie  (von  Frisch  und  2uckerkandl),  1905,  ii.  589. 

INVERSION  AND  PROLAPSE  OF  THE  BLADDER 
(URETHRAL  CYSTOCELE) 

There  are  two  forms  of  urethral  cystocele.  In  one,  inversion 
of  the  bladder,  the  whole  thickness  of  the  bladder  wall,  including 
the  peritoneal  investment,  is  inverted  through  the  urethra,  while 
in  the  second  the  mucous  membrane  is  prolapsed  through  the 
urethra.  The  condition  occurs  in  women  and  female  children. 
(Gross  collected  7  cases  of  complete  inversion,  5  in  girls  between 
14  months  and  4  years,  and  2  in  adult" women.) 

Etiology. — Except  in  one  or  two  cases  in  which  the  urethra 
was  destroyed,  little  is  known  in  regard  to  the  causation.  But 
the  exciting  causes  are  straining  from  crying,  coughing,  sneezing, 
constipation,  and  diarrhoea.  Hirokawa  has  described  a  case 
following  pertussis. 

Varieties  and  diagnosis. — Inversion  of  the  bladder,  which 
is  very  rare,  varies  in  degree,  (i)  The  whole  bladder  may  be 
inverted  into  the  urethra  and  appear  at  the  external  meatus 
as  a  round  swelling,  the  size  of  a  walnut  or  an  orange,  covered 
with  reddened,  easily  bleeding  mucous  membrane.  The  tumour 
is  tender,  elastic,  increases  in  size  on  crying  or  straining,  and  is 
felt  to  consist  of  several  layers.  It  is  reducible  with  difficulty  or 
not  at  all.  If  it  project  well  beyond  the  urethral  orifice  it  appears 
to  be  pedunculated,  and  a  probe  passed  along  the  urethra  beside 
the  pedicle  enters  the  bladder  and  can  be  swept  round  the 
pedicle  on  all  sides.  Rarely  the  ureteric  orifices  are  carried  down 
with  the  prolapsed  bladder,  and  can  be  recognized  emitting  drops 
of  urine  on  the  surface  of  the  tumour.  The  patient  complains  of 
incontinence  of  urine. 


410  THE   BLADDER  [chap. 

(ii)  In  an  incomplete  form  of  inversion  the  bladder  wall  is 
folded  inwards  into  the  cavity  of  the  viscus,  but  is  not  prolapsed 
through  the  urethra.  This  variety  is  said  to  occur  in  men  as  well 
as  in  women.  The  diagnosis  is  only  made  by  cystoscopy.  Symp- 
toms resembling  those  of  stone  in  the  bladder  are  usually  present. 
There  are  increased  frequency,  pain  on  micturition  and  tenesmus^ 
intermittent  micturition,  and  the  stream  may  only  be  initiated 
or  recommenced  by  lying  on  the  back.     Heematuria  is  rare. 

Prolapse  of  the  vesical  mucous  membrane  is  more  frequent  than 
inversion.  An  area  of  mucous  membrane  is  prolapsed  through 
the  urethra.  According  to  Malherbe  a  glandular  cul-de-sac  in  the 
neighbourhood  of  the  internal  meatus  becomes  distended  with 
urine  so  that  a  ridge  of  mucous  membrane  is  raised,  and  this, 
becomes  pedunculated.  A  small  tumour  of  mucous  membrane 
appears  at  the  external  meatus.  It  has  a  translucent  appear- 
ance and  is  compressible. 

The  diagnosis  from  inversion  of  the  bladder  wall  is  made  by 
the  sensation  of  greater  thickness  and  the  presence  of  the  ureteric 
orifices  on  the  surface  of  the  tumour  in  the  inversion.  A  tumour 
of  the  bladder  which  has  prolapsed  through  the  urethra  is  firmer^ 
does  not  vary  in  size,  and  is  not  compressible. 

In  prolapse  an  instrument  passes  alongside  the  tumour  into 
the  bladder,  and  can  be  swept  round  it,  but  is  not  free  in  the 
cavity  when  it  has  passed  the  urethra.  When  it  has  been  reduced, 
cystoscopy  shows  that  there  is  no  growth  or  prolapse  of  the  ureter. 
Polypi  of  the  urethra  may  protrude  from  the  meatus,  but  they 
are  small,  and  the  attachment  of  the  base  to  the  urethral  mucous 
membrane  can  be  demonstrated  by  a  speculum  or  urethroscope 
tube.  Prolapse  of  the  ureter  has  appeared  at  the  external  meatus 
in  the  female  subject,  but  the  thin,  transparent  appearance  of 
the  tumour  and  cystoscopic  examination  will  make  the  diagnosis 
plain. 

Treatment. — There  are  few  cases  recorded  on  which  to  base 
statements  in  regard  to  treatment.  The  tumour  has  been  reduced 
and  has  not  recurred  (Leech).  Leedham- Green  reduced  the 
inversion  in  his  case  and  injected  melted  paraffin  in  a  ring  around 
the  urethra ;  the  hardened  paraffin  gave  support  to  the  urethra, 
and  recurrence  did  not  take  place. 

Cysto-uteropexy  has  been  performed,  the  upper  part  of  the 
bladder  being  fixed  to  the  anterior  surface  of  the  uterus.  This 
was  successful  in  a  case  recorded  by  Peigne.  Plastic  operations 
on  the  urethra  are  necessary  when  prolapse  has  recurred. 

When  the  mucous  membrane  is  prolapsed  the  polypoid  portion 
should  be  removed  by  suprapubic  cystotomy. 


XXX]  DIVERTICULA   OF   BLADDER  411 

LITERATURE 

Carrel,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1900,  p.  299. 
Hirokawa,  Denis.  Zeits.  f.  Chir.,  1911,  p.  575. 
Leech,  Brit.  Med.  Joiirn.,  189G,  ii.  1128. 
Leedham-Green,  Brit.  Med.  Journ.,  1908,  i.  970. 
Lowe,  Arch.  j.  IcLin.   Chir.,  v.  305. 

DIVERTICULA  OF  THE  BLADDER 

A  diverticulum  is  a  pouch  lined  by  vesical  mucous  membrane 
which  communicates  with  the  bladder  by  a  narrow  opening. 

Diverticula  should  be  distinguished  from  the  pouches  or  sac- 
cules of  a  sacculated  bladder,  which  is  commonly  seen  in  prostatic 
obstruction,  where  there  is  widespread  or  universal  trabeculation, 
and  between  the  trabeculse  are  innumerable  shallow  and  deep 
depressions,  open,  without  contraction  of  the  orifice,  to  the  bladder 
cavity. 

Pathological  anatomy.^Diverticula  may  be  single  or  mul- 
tiple, small  as  a  pea  or  as  large  as  the  bladder  cavity,  or  even 
larger.  Small  diverticula  may  be  solitary,  but  they  are  frequently 
multiple,  and  when  multiple  are  frequently  arranged  in  groups 
of  two  or  three,  or  even  six  or  seven  sometimes,  symmetrically 
arranged  on  each  side  of  the  bladder. 

The  orifice  is  small.  It  may  barely  admit  a  crow-quill,  but 
more  frequently  will  pass  a  pencil,  or  even  the  forefinger.  The 
size  of  the  orifice  has  no  relation  to  the  capacity  of  the  diverti- 
culum. The  edges  are  sharply  defined.  The  opening  frequently 
appears  as  a  round  hole  punched  out  in  an  absolutely  healthy 
bladder  wall.  An  oval  or  slit-like  orifice  is  sometimes  found,  but 
is  rare.. 

General  trabeculation  of  the  bladder  wall  is  seldom  if  ever 
present.  Trabeculation  limited  to  an  area  around  the  orifice  of 
the  diverticulum  is  frequently  found,  and  may  be  confined  to  the 
wall  at  one  part  of  the  circumference  of  the  orifice. 

The  mucous  membrane  frequently  shows  puckerings  and  ridges 
which  radiate  from  the  orifice  at  one  part  of  the  circumference 
or  all  round.  They  resemble  the  puckering  of  the  peritoneum 
at  the  neck  of  a  hernia  when  viewed  from  within  the  abdomen, 
and  give  "the  impression  that  the  mucous  membrane  is  being 
dragged  upon  from  without  the  bladder.  (Plate  30,  Figs.  1,  2.) 
When  situated  in  the  neighbourhood  of  the  ureter  the  interureteric 
bar  is  usually  hypertrophied  on  that  side. 

The  ureteric  orifice  may  open  in  the  wall  of  the  diverticulum 
or  on  the  margin  of  the  mouth  of  the  diverticulum.  In  the  former 
case  the  ureter  has  probably  become  dragged  into  the  cavity  in 
the  process  of  development  of  the  sac. 


412  THE   BLADDER  [chap. 

Diverticula  may  be  found  at  any  part  of  the  bladder.  They 
are  most  frequently  found  on  the  lateral  walls,  in  the  neighbour- 
hood of  the  ureteric  orifice,  and  next  on  the  posterior  wall.  Less 
frequently  they  are  found  at  the  apex.  Rarely  they  open  on  the 
trigone.  I  have  seen  the  opening  of  a  very  large  diverticulum  in 
the  middle  line  near  the  posterior  part  of  the  trigone. 

The  structure  of  the  wall  varies.     The  cavity  is  lined  by  mucous' 
membrane  continuous  with  and  similar  to  that  of  the  bladder, 
and  is  surrounded  by  fibrous  tissue  and  usually  by  a  consider- 
able quantity  of  coarse  fat.     In  some  diverticula  there  is  a  layer 
of  non-striped  muscle,  while  in  others  this  is  wanting. 

Virchow,  Englisch,  and  others  hold  that  when  the  muscle  is 
present  the  diverticulum  is  congenital,  and  when  absent  the  diver- 
ticulum is  acquired.  Young  was  always  able  to  find  muscle  in 
the  walls  of  diverticula,  although  the  layer  might  be  very  thin. 

Diverticula  may  have  secondary  pockets,  and  they  are  usually 
extensively  adherent  to  the  pelvic  viscera. 

Etiology. — The  great  majority  of  diverticula  are  found  in 
men,  but  they  sometimes  occur  in  infants.  They  are  frequently 
met  with  in  young  adults  or  in  middle  age. 

While  many  of  the  diverticula  are  congenital,  some  are  appar- 
ently due  to  urethral  obstruction,  and  are  met  with  in  cases  of 
stricture  and  enlarged  prostate.  In  some  cases  I  have  found  a 
history  of  pelvic  cellulitis  (from  appendicitis,  salpingitis,  etc.), 
and  traction  from  without  by  adhesions  may  have  been  a  factor. 
Diverticula  at  the  apex  of  the  bladder  result  from  incomplete 
obliteration  of  the  urachus. 

Symptoms. — These,  apart  from  the  symptoms  of  obstruction 
due  to  stricture  or  enlarged  prostate  which  are  present  in  some 
cases,  and  the  symptoms  of  such  complications  as  cystitis  or  new 
growth,  are  usually  puzzling  and  irregular. 

In  a  young  man  with  clear  urine  there  may  be  attacks  of 
frequent  micturition  at  varying  intervals,  or  continuously.  In 
other  cases  there  are  attacks  of  complete  retention,  relieved  by 
catheter,  or  there  may  be  gradually  increasing  difficulty  in  mic- 
turition, culminating  in  complete  retention.  In  these  cases  I  have 
usually  found  spasmodic  contraction  of  the  compressor  urethrse. 

In  many  cases  there  are  no  symptoms  which  can  be  ascribed 
to  the  diverticulum,  and  it  is  discovered  accidentally  during 
examination  of  the  bladder  for  some  other  disease. 

Micturition  in  two  parts  is  a  symptom  which  has  been  described, 
but  is  rarely  seen  except  in  very  large  diverticula.  Sometimes 
the  second  supply  is  purulent  when  the  first  was  clear. 

On   passing   a   catheter   a   somewhat   similar   phenomenon   is 


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XXX]  DIVERTICULA  OF   BLADDER  413 

observed.  The  bladder  is  apparently  emptied,  when  the  point 
of  the  catheter  slips  onwards  and  a  large  quantity  of  urine,  some- 
times purulent,  is  passed.  With  a  sound  it  is  sometimes  possible 
to  feel  the  edge  of  the  aperture  with  the  beak. 

One  or  several  ounces  of  residual  urine  may  be  drawn  of!  by 
catheter  after  the  patient  has  passed  all  he  can. 

Small  diverticula  cannot  be  felt  on  abdominal  or  rectal  palpa- 
tion. A  large  diverticulum  can  be  felt  as  a  tumour  in  the  lower 
part  of  the  abdomen.  In  an  extensive  diverticulum  on  the  right 
side  of  the  bladder  I  could  feel  a  large  fluctuating  mass  in  the  right 
iliac  fossa  when  the  bladder  was  distended  with  fluid,  and  this 
almost  disappeared  when  the  bladder  was  emptied.  The  diverti- 
culum was  apparently  adherent  to  the  caecum.  Eventually  a 
malignant  growth  developed  in  the  diverticulum,  and  the  patient 
died  of  pyelonephritis. 

Diagnosis. — The  symptoms  are  frequently  those  of  cystitis 
with  residual  urine  which  is  purulent.  The  only  certain  method 
of  diagnosis  is  cystoscopy.  The  extent  of  the  diverticulum  cannot 
be  gauged  by  the  cystoscopy  A  stone  lying  in  a  diverticulum  is 
sometimes  seen  cystoscopically.  Usually,  however,  the  orifice  is 
so  small  that  even  a  large  stone  cannot  be  seen.  Drawings  of 
the  orifices  of  diverticula  are  seen  in  Plate  30,  Figs.  1,  27,  and  the 
skiagram  of  a  large  stone  which  one  contained  is  shown  in  Plate  29, 
Fig.  1.     The  stone  could  not  be  seen  by  cystoscopy. 

To  demonstrate  the  dimensions  and  position  of  a  diverticulum, 
the  bladder  should  be  distended  with  an  emulsion  of  bismuth  and 
a  skiagram  obtained.     (Plate  27,  Fig.  2,  and  Plate  29,  Fig.  3.) 

Complications.' — 1.  By  pressure  or  dragging  upon  the  ureter 
dilatation  of  the  kidney  may  be  produced.  Both  kidneys  may 
be  affected. 

2.  Infection  is  a  common  and  very  serious  complication,  and 
is  usually  due  to  septic  catheterization.  There  may  be  acute 
general  cystitis  lasting  for  many  weeks  and  finally  subsiding,  but 
recurring  from  time  to  time,  or  there  is  continuous  subacute 
cystitis  with  recurrent  exacerbations. 

A  collection  of  purulent  urine,  sometimes  decomposing,  is 
lodged  in  the  diverticulum  and  pours  out  into  the  bladder  from 
time  to  time.  Pericystitis  and  peritonitis  may  occur.  Ascending 
pyelonephritis  is  the  usual  termination  in  these  cases. 

3.  A  calculus  may  form  in  the  diverticulum,  and  may  follow 
long-standing  infection  of  the  diverticulum,  but  it  also  forms 
where  a  very  mild  infection  is  present. 

4.  A  malignant  growth  may  develop  on  the  edge  or  in  the  neigh- 
bourhood  of  the   orifice,    or  may   arise   within  the   diverticulum. 


414 


THE  BLADDER 


[chap. 


I  have  seen  instances  of  each  of  these,  and  operated  upon  three 
cases  of  the  former. 

Prognosis. — The  presence  of  a  diverticulum  is  not  in  itself 
dangerous,  but  when  infection  has  taken  place  the  prognosis  is 
extremely  grave.  Ascending  pyelonephritis  supervenes  in  these 
cases.     Malignant  growth  occurs  in  a  small  percentage  of  cases. 

Treatment. — The  grea,t  danger  of  infection  should  render  the 


Fig.  119. — Operation  specimen  of  resection  of  bladder  wall. 

The  upper  portion  shows  the  excised  part  of  the  bladder  wall,  on  which  is  set  a  malignant  growth. 

Below  this  is  the  orifice  of  a  diverticulum  with  the  diverticulum  itself.      To  the  left  is  the  lower 

end  of  the  ureter,  in  which  lies  a  bristle.     The  ureter  was  transplanted  ;  perineal  prostatectomy 

three  weeks  later  ;  recovery. 

surgeon  doubly  careful  in  regard  to  asepsis.  Where  infection  has 
occurred,  washing  the  bladder  has  little  effect  upon  the  contents 
of  the  diverticulum.  In  the  female  subject  a  Kelly's  tube  may 
be  passed  and  a  catheter  introduced  through  this  into  the  orifice 
and  the  diverticulum  washed  out, 

A  number  of  operations  have  been  performed : 

1,  Drainage    outside   the    bladder. — This  may   be   tried  in 


XXX]  DIVERTICULA   OF   BLADDER  415 

large  diverticula,  but  is  impossible  in  small  pockets  and  in  those 
at  the  base  of  the  bladder.  This  method  leads  to  a  permanent 
urinary  fistula.  It  may,  however,  be  combined  with  the  next 
method. 

2.  Closure  of  the  orifice. — After  suprapubic  cystotomy  the 
edges  of  the  orifice  are  cut  away  and  the  raw  surfaces  brought 
together.     The  diverticulum  must  previously  have  been  aseptic. 

3.  Drainage  into  the  bladder. — The  walls  of  the  bladder 
and  diverticulum  are  split  upwards  or  downwards  and  the  edges 
stitched  together  so  that  the  cavity  of  the  diverticulum  is  thrown 
into  that  of  the  bladder.  This  permits  of  free  drainage  of  the 
diverticulum  into  the  bladder,  and  the  cavity  is  more  readily 
cleaned  by  washing  the  bladder. 

4.  Excision  of  the  sac  and  repair  of  the  bladder  wall. — 
This  has  been  performed  by  several  surgeons,  and  I  have  carried 
it  out  in  six  cases.  In  the  upper  part  of  the  bladder  the  operation 
does  not  present  great  difficulties,  but  it  may  be  extremely  difficult, 
owing  to  extensive  adhesions,  in  diverticula  deeply  situated  in  the 
pelvis.  A  urinary  fistula  has  persisted  in  some  recorded  cases 
and  necessitated  secondary  operations.  In  one  of  my  cases  a  small 
pocket  deeply  placed  in  the  pelvis  had  been  left  and  caused  a 
purulent  discharge  for  some  time,  but  the  communication  with 
the  bladder  closed  at  once.  In  another  case  (Fig.  119)  I  removed 
a  large  malignant  growth  by  resection  of  the  bladder  wall,  and 
with  it  a  diverticulum  full  of  stones,  and  the  lower  part  of  the 
ureter,  transplanting  the  ureter  into  the  wound.  A  fortnight 
later  an  enlarged  prostate  was  removed  from  the  perineum.  The 
patient,  aged  73,  made  an  uneventful  recovery. 

In  order  to  facilitate  removal  of  the  sac,  Lerche  introduced  a 
small  collapsed  rubber  bag  on  the  end  of  a  fine  catheter  into  the 
diverticulum,  and  then  distended  it  with  fluid. 

LITERATURE 

Berry,  Proc.  Eoy.  Soc.  Med.,  Surgical  Section,  1911,  p.  158. 

Chute,  Boston  Med.  and  Surg.   Journ.,  Sept.,  1912,  p.  316. 

Durrieux,  These  de  Paris,  1901. 

Englisch,  Wien.  Min.   Woch.,  1894,  p.  91. 

Lerche,  Ann.  Surg.,  Nov.,  1911,  p.  593;  Feb.,  1912,  p.  285. 

Pagenstecher,  Arch.  f.  Uin.  Chir.,  1904,  p.  186. 

Targett,   Trans.  Path.  Soc.,  1896,  p.  155. 

Young,  Johns  Hopkins  Eosp.  Repts.,  1906,  p.  401. 


CHAPTER  XXXI 
INJURIES  OF  THE  BLADDER 

RUPTURE 

In  rupture  of  the  bladder  the  outer  coat  may  remain  intact,  or 
more  commonly  the  whole  thickness  of  the  vesical  wall  is  torn. 
The  great  majority  of  cases  (90  per  cent.)  take  place  in  male  sub- 
jects, and  usually  during  the  most  active  period  of  life  (20  to  40 
years).  The  injury  is  said  to  occur  more  frequently  in  England 
and  America,  owing  to  the  greater  prevalence  of  field  sports  and 
boxing. 

The  bladder  is  invariably  full  at  the  time  of  rupture,  some- 
times it  is  over-distended.  A  considerable  proportion  of  cases 
(35  per  cent. — Bartels)  occur  during  alcoholic  intoxication. 

The  injury  is  usually  direct,  as  from  kicks,  blows  with  the 
fist  or  knee,  falls  upon  furniture  or  boulders,  crushes  between 
buffers  or  from  machinery.  In  fracture  of  the  pelvis  a  splinter 
of  bone  may  penetrate  the  bladder.  The  injury  may  also  be 
due  to  indirect  violence,  such  as  falls  from  a  height  or  being 
thrown  from  a  vehicle.  The  bladder  may  be  ruptured  by  the 
muscular  effort  of  lifting  heavy  weights,  or  by  straining  under  an 
ansesthetic.  Rupture  has  taken  place  from  the  effort  of  blowing 
a  trumpet  (Fenwick),  and  from  leaning  over  the  edge  of  a  barrel 
(Zuckerkandl). 

Over-distension  of  the  bladder  has  caused  rupture  from  great 
intravesical  pressure.  This  usually  occurs  from  the  forcible 
injection  of  fluid  by  the  surgeon  into  the  bladder.  It  has  been 
known  to  occur  from  the  action  of  the  evacuating  bulb  after  the 
operation  of  litholapaxy.  It  is  very  doubtful  if  the  bladder  can 
be  ruptured  by  intravesical  tension  from  the  collection  of  urine 
when  the  organ  is  healthy.  Cases  have,  however,  been  described 
to  show  the  possibility  of  such  an  occurrence. 

In  a  bladder  the  seat  of  malignant  or  other  ulceration  rupture 
may  take  place  spontaneously. 

Pathology. — A  few  cases  of  incomplete  rupture  have  been 
recorded,  but  they  are  very  rare.     In  a  case  described  later,  only 

416 


( iiAi.  xxxij         RUPTURE   OF   BLADDER  417 

the  iiuicous  membrane  was  torn.  The  rupture  is  most  frequently 
oil  the  postero-superior  wall,  and  opens  the  peritoneal  cavity. 

Extraperitoneal  rupture  occurs  exceptionally,  and  affects  the 
anterior  wall.  Rupture  of  the  base  and  lateral  walls  is  usually 
the  result  of  fracture  of  the  pelvis.  The  rupture  is  vertical,  and 
in  or  near  the  middle  line ;  it  is  single,  and  is  usually  small  in 
size,  with  clean-cut  or  bruised  edges.  Later,  inflammatory 
reaction  is  found  around  the  wound.  Rarely  the  tear  is  trans- 
verse or  irregular. 

When  the  peritoneal  cavity  is  opened,  coils  of  intestine  may 
exceptionally  become  adherent  and  limit  the  extravasation  of 
urine  and  peritonitis.  Usually,  urine  escapes  into  the  peiitoneal 
cavity,  and  general  peritonitis  supervenes.  When  the  urine  is 
already  septic  this  appears  rapidly.  Aseptic  urine  does  not  cause 
peritonitis,  but  it  is  toxic  when  absorbed,  and  even  if  aseptic  at 
the  time  of  the  accident  it  very  readily  becomes  infected.  In 
extraperitoneal  rupture  the  urine  infiltrates  the  pelvic  cellular 
planes,  and  infianmiation  and  suppuration  follow. 

Fracture  of  the  pelvis  is  present  in  38  per  cent,  of  cases 
(Bartels),  the  pubic  bones  being  the  most  frequent  seat  of  frac- 
ture, then  the  ischium,  ilium,  and  sacrum.  The  mechanism  by 
which  the  rupture  is  produced  is  open  to  discussion.  It  is  stated 
that  contact  of  the  distended  bladder  with  the  pubic  bone  or 
with  the  promontory  of  the  sacrum  is  the  cause,  and  that  the 
greater  liability  of  the  posterior  wall  to  rupture  is  due  to  its  being 
unsupported  when  compared  with  the  anterior  wall,  and  to  the 
more  frequent  occurrence  on  it  of  saccules  and  diverticula. 

When  the  bladder  is  fully  distended  above  the  pubes  the 
danger  from  an  antero-posterior  blow  is  rupture  of  the  postero- 
superior  wall,  while  a  partly  distended  bladder  is  more  likely  to 
be  driven  down  into  the  pelvis  and  sustain  injury  to  the  base. 
The  slower  forms  of  violence  are  said  to  be  more  likely  to  produce 
a  partial  rupture. 

Symptoms. — Shock  is  present  as  in  other  abdominal  injuries, 
and  is  pronounced  and  frequently  prolonged,  but  it  may  be  absent, 
and  when  the  rupture  is  uncomplicated  by  other  injuries  some 
time  may  elapse  before  other  symptoms  appear.  These  are  pain, 
great  desire  to  micturate,  and  straining,  but  inability  to  pass 
water.  The  spasms  come  on  at  intervals,  and  may  be  very  severe. 
The  abdomen  is  rigid,  and  tender  on  palpation.  There  is  no  dull- 
ness corresponding  to  a  distended  bladder,  and  the  patient  has 
not  passed  water  for  several  hours.  Per  rectum  there  is  bulging 
in  the  pouch  of  Douglas. 

On  a  catheter  being  introduced  a  little  bloody  urine  is  with- 
2  b 


418  THE   BLADDER  [chap. 

drawn.  Rarely  the  catheter  passes  through  the  rent  in  the 
bladder  wall  into  the  peritoneal  cavity,  and  a  very  large  quantity 
of  urine  can  be  drawn  off.  If  a  catheter  is  passed  several  times 
within  a  short  space  it  is -found  that  the  quantity  of  urine  in  the 
bladder  is  always  the  same,  for  any  excess  of  fluid  escapes  into 
the  peritoneum.  If,  after  emptying  the  bladder,  the  patient  be 
set  upright  for  a  very  short  time,  a  quantity  of  urine  will  be  found 
to  have  filled  the  bladder  again,  having  passed  in  from  the  peri- 
toneal cavity  (Morel). 

When  the  rupture  is  extraperitoneal,  dullness  appears  above 
the  pubes,  and  there  are  tenderness  and  rigidity.  The  infiltration 
spreads  in  the  pelvis  and  escapes  by  the  sciatic  notch  into  the 
buttock,  by  the  obturator  foramen,  into  the  upper  part  of  the  thigh, 
or  along  the  inguinal  canal  into  the  scrotum.  Abscess  formation 
and  the  development  of  fistulae  follow,  and  then  thrombosis  of 
veins  and  septicaemia. 

In  intraperitoneal  rupture,  peritonitis  appears  within  the  first 
twelve  hours,  the  abdomen  becomes  distended,  there  are  vomiting, 
hiccough,  a  rapid  pulse,  and  other  signs  of  severe  peritoneal  infec- 
tion. Death  may  rarely  take  place  without  signs  of  peritonitis, 
and  is  then  probably  due  to  the  toxic  effect  of  the  urine. 

In  a  case  of  partial  rupture  of  the  bladder  which  I  was  asked 
to  see  by  my  colleague  Mr.  Jackson  Clarke,  a  boy  aged  5  was 
knocked  down  by  a  motor  car,  but  it  was  doubtful  if  the  wheels 
had  passed  over  him.  Soon  after  the  accident  he  passed  urine 
containing  bright  blood.  Seven  hours  after  the  accident  he  was 
suffering  from  shock,  there  was  a  hsematoma  over  the  left  iliac 
crest,  left  loin,  and  left  inguinal  region.  The  abdomen  was  slightly 
rigid,  and  there  was  tenderness  to  the  right  of  the  umbilicus  and 
in  the  hypogastrium.  The  pelvic  girdle  was  intact.  On  passing 
the  catheter,  clear  urine  flowed  at  first  and  was  followed  by  bright 
blood.  The  blood  disappeared  from  the  urine  in  twenty-four 
hours.  Cystoscopy  six  days  after  the  accident  showed  the  whole 
mucous  membrane  of  the  bladder  dotted  with  tiny  petechiee  like 
a  rash ;  in  some  places  they  were  grouped.  On  the  right  side 
of  the  bladder  near  the  apex  there  was  a  gutter -like  tear  of  the 
mucous  membrane  about  |  in.  in  length.  The  edges  were  sharp, 
raised,  and  slightly  everted.  The  base  was  red  and  granular. 
(Plate  30,  Fig.  3.)     Convalescence  was  uneventful. 

Diagnosis. — The  diagnosis  depends  upon  the  history  of  an 
injury  and  the  feeling  of  something  having  given  way,  followed 
by  strangury  and  the  inability  to  pass  urine,  and  by  the  bladder 
being  found  empty  with  the  catheter,  or  only  a  small  quantity  of 
blood-stained  urine  being  withdrawn. 


xxxij  RUPTURE   OF   BLADDER  419 

From  rupture  of  the  urethra  the  diagnosis  is  made  by  the 
absence  of  blood  at  the  meatus  and  of  perineal  swelhng,  both  of 
which  are  characteristic  of  injuries  to  the  urethra. 

In  rupture  of  the  kidney  there  may  be  symptoms  similar  to 
those  of  rupture  of  the  bladder.  The  history  of  the  blow  in  the 
lumbar  region,  the  comparative  absence  of  bladder  irritation, 
and  the  absence  of  pain  in  passing  water,  together  with  tenderness 
in  the  loin,  are  characteristic  features  of  renal  injury. 

In  cases  of  fracture  of  the  pelvis  it  is  often  doubtful  if  the 
bladder  is  ruptured,  and  the  more  so  that  retention  of  urine  is 
frequently  present.  In  these  cases  the  bladder  will  be  found 
distended.  On  rectal  examination  the  pouch  of  Douglas  is  not 
filled  with  fluid.  On  passing  a  catheter  the  urine  is  drawn  off, 
while  in  rupture  of  the  bladder  a  small  quantity  of  blood-stained 
urine  dribbles  feebly  away. 

The  injection  of  fluids  into  the  bladder  in  order  to  ascertain 
if  a  smaller  quantity  is  returned,  and  thus  assist  in  the  diagnosis 
of  rupture,  is  to  be  deprecated,  for  there  is  very  grave  danger 
of  carrying  infection  and  increasing  the  extravasation  of  fluid. 
The  inflation  of  the  bladder  with  air,  which  will  escape  into  the 
peritoneal  cavity  and  obliterate  the  liver  dullness,  is  equally 
dangerous.  Cystoscopy  is  only  of  service  in  partial  rupture ;  in 
complete  rupture  it  is  not  of  diagnostic  value,  as  distension  of 
the  viscus  cannot  be  obtained. 

When  there  is  a  fracture  of  the  pelvis  the  rupture  is  more 
likely  to  be  extraperitoneal.  Here  also  there  are  no  signs  of  peri- 
tonitis and  no  rigidity  of  the  abdominal  muscles.  In  the  rectum 
the  finger  can  feel  a  tender  swelling,  and  there  may  be  ecchymoses 
around  the  anus.  Exploration  of  the  bladder  by  suprapubic 
cystotomy  is  the  most  satisfactory  method  of  making  an  exact 
diagnosis,  and  is  a  preliminary  to  treatment. 

Treatment. — In  complete  rupture  operation  should  be  per- 
formed as  soon  as  the  diagnosis  is  made,  unless  the  shock  is  very 
profound,  when  a  few  hours'  delay  is  permissible  in  order  to  allow 
the  patient  to  rally. 

When  the  diagnosis  of  intraferitoneal  rupture  is  clearly  estab- 
lished, the  abdomen  is  opened  in  the  middle  line  below  the 
umbilicus,  and  the  urine  and  blood  mopped  up.  The  patient  is 
then  raised  into  the  Trendelenburg  position,  the  intestines  packed 
aside,  and  the  peritoneal  surface  of  the  bladder  carefully  examined. 
If  the  opening  is  within  reach  its  extent  is  examined  and  brought 
up  as  near  the  surface  as  possible,  and  sutured  in  two  layers,  and 
Lembert's  sutures  added.  A  catheter  should  be  tied  in  the  urethra 
and  a  drain  placed  in  the  peritoneum.     If  the  wound,  from  its 


420  THE  BLADDER  [chap. 

position,  is  inaccessible,  it  will  only  be  possible  to  drain  the  peri- 
toneum and  to  tie  a  catheter  in  the  urethra. 

When  the  rupture  is  extraferitoneal  a  suprapubic  incision  is 
made  down  to  the  bladder  and  the  anterior  face  examined.  If 
the  rupture  is  easily  accessible  it  is  sutured  and  a  suprapubic 
drain  inserted  in  the  bladder.  If  the  rupture  is  inaccessible — a 
very  rare  condition  when  the  Trendelenburg  position,  good  re- 
traction, and  proper  lighting  are  used — the  bladder  is  drained 
suprapubically,  and  if  necessary  a  counter-drain  is  inserted  in 
the  perineum. 

Results. — Dambrin  and  Papin  found  that  the  mortality  of 
operations  in  intraperitoneal  rupture  was  43-5  per  cent,  in  78  cases, 
and  when  only  the  last  six  years  were  taken  the  mortality  fell  to 
20-5  per  cent.  Death,  when  it  occurred,  was  due  to  peritonitis, 
shock,  Urinary  toxaemia,  and  haemorrhage.  The  earlier  operation 
is  performed  in  intraperitoneal  rupture  the  better  the  prognosis. 
Of  13  cases  operated  on  within  the  first  twelve  hours  after  the 
injury,  8  recovered  ;  while  of  21  cases  operated  on  after  this  limit, 
15  died  (Zuckerkandl).  At  the  same  time  it  is  never  too  late 
for  operation,  for  recoveries  have  been  recorded  when  six  days 
have  elapsed  (Blumer),  and  Quick  successfully  operated  on  a 
case  ten  days  fourteen  hours  after  the  injury. 

In  non-operated  cases  of  extraperitoneal  rupture  Zuckerkandl 
gives  a  mortality  of  27  per  cent.  Collected  cases  in  which  there 
was  urinary  extravasation  show  a  high  operative  mortality. 
Mitchell  collected  90  cases  with  a  mortality  of  83  per  cent,  in 
1898. 

Of  49  collected  cases  of  extraperitoneal  rupture,  Wolfer  found 
that  6  were  fatal,  and  of  18  cases  of  intraperitoneal  rupture  9 
were  fatal. 

WOUNDS 

Bullet  wounds  of  the  bladder  are  not  common,  but  Bartels 
could  collect  285  cases  from  the  literature.  Both  in  civil  and 
in  military  practice  they  are  usually  incurred  when  the  bladder 
is  distended.  Stab  wounds  of  the  bladder  from  a  bayonet  or 
dagger  are  rare.  Accidental  wounds  during  surgical  operations 
are  met  with  when  the  bladder  is  drawn  into  a  hernial  sac,  in 
operations  on  the  uterus,  and  in  symphysiotomy.  Falls  upon 
sharp  objects  on  which  the  patient  is  impaled  are  not  infrequent. 
Puncture  of  the  bladder  base  during  attempts  at  abortion  has 
been  recorded.  The  wound  is  almost  invariably  complete,  and 
frequently  double.     It  may  be  intra-  or  extraperitoneal. 

Bladder   wounds   are   usually   complicated   by   injury   to   the 


xxxi]  WOUNDS   OF   BLADDER  421 

I)()iiy  pelvis,  I'ccfun),  utciiis,  va<^iiia,  or  iiiciJira.  Foicij^ii  bodies 
are  fre(|U('iitly  cai'ried  into  the  wound,  with  ('(xiscMuieut  infection. 
Ill  intraperitoneal  wounds  a  small  opening  may  rarely  be  plujrfied 
by  omentum  or  adherent  bowel.  Usually  there  is  extravasation 
of  urine,  followed  by  acute  peritonitis.  In  extraperitoneal  wounds 
there  are  extravasation  and  suppuration,  leading  to  urinary  fistulae. 

Symptoms. — Shock  is  usually  present,  and  may  be  profound. 
There  are  pain,  tenesmus,  and  frequent  desire  to  pass  water,  with 
inability  to  do  so ;  often  a  few  drops  of  blood  are  passed  after 
much  straining.  Rectal  spasm  may  also  be  present.  Urine 
mixed  with  blood  may  escape  by  the  wound,  especially  when  it 
is  extensive.  The  escape  of  urine  may  be  prevented  by  plugging 
of  the  wound  with  bowel,  or  by  the  urine  escaping  into  the 
peritoneal  cavity  through  a  second  wound.  In  other  cases, 
in  which  the  wound  is  small  and  the  track  oblique,  urine  may 
only  escape  during  attempts  at  micturition.  Occasionally  there 
is  profuse  haemorrhage  from  the  external  wound.  Faeces  and 
flatus  may  escape  from  the  wound  with  the  urine  when  the 
rectum  is  wounded.  Spontaneous  closure  of  a  small  intraperi- 
toneal wound  has  been  observed  (Makins),  but  this  is  rare,  and 
peritonitis  almost  invariably  supervenes.  The  peritonitis  may 
be  delayed  until  the  separation  of  sloughs  on  the  seventh  or  eighth 
day.  In  small,  oblique  extraperitoneal  wounds  there  is  perivesical 
and  periurethral  extravasation  of  urine  which  becomes  infected. 
This  is  followed  by  thrombosis  in  the  vesical  and  prostatic  veins. 

Fistulae  are  very  common,  especially  after  bullet  wounds. 
Recto-vesical  and  vesico-vaginal  fistulae,  and  surface  fistulae  on 
the  abdomen,  scrotum,  perineum,  thighs,  and  buttocks,  result 
from  suppuration  and  urinary  infiltration.  Bartels  found  that 
23  cases  out  of  67  had  a  fistula  for  from  six  to  twelve  months, 
and  in  5  the  fistula  was  permanent.  In  many  cases  foreign 
bodies,  such,  as  bullets,  fragments  of  bone,  etc.,  are  found  in  the 
bladder,  and  phosphatic  calculi  containing  foreign  bodies  are 
frequent. 

Diagnosis. — The  escape  of  urine  from  the  wound  and  the 
presence  of  blood  in  the  urine  passed  or  drawn  by  a  catheter, 
and  tenesmus  of  the  bladder,  are  sufficient  to  establish  the  diag- 
nosis. Examination  of  a  perineal  wound  with  a  metal  instru- 
ment in  the  bladder  will  assist.  The  diagnosis  as  to  whether  the 
wound  is  extra-  or  intraperitoneal  may  be  impossible  at  first,  _ 
and  it  is  important  not  to  wait  until  symptoms  of  peritonitis 
appear  before  operating. 

Prognosis. — Intraperitoneal  wounds  are  grave  from  the  cer- 
tainty of  infection  and  the  frequency  of  injury  to  other  organs, 


422  THE   BLADDER  [chap,  xxxi 

such  as  the  bowel.  Extraperitoneal  wounds  have  a  much  better 
prognosis. 

Treatment. — The  treatment  is  that  of  penetrating  wounds 
of  the  lower  abdomen.  Laparotomy  should  be  performed  as 
early  as  possible,  and  the  peritoneal  surface  of  the  bladder  exam- 
ined and  any  wound  closed.  Wounds  of  the  intestine  are  searched 
for  and  sutured.  If  the  bladder  wound  is  not  found  on  the  peri- 
toneal surface  the  peritoneum  is  closed  and  the  anterior  surface 
of  the  bladder  examined.  If  a  wound  is  found  it  may,  if  the 
position  is  suitable,  be  used  to  drain  the  bladder,  or  the  wound 
may  be  closed  and  a  catheter  tied  in  the  urethra. 

When  the  bladder  has  been  wounded  from  the  perineum  the 
wound  should  be  carefully  examined  and  free  drainage  provided. 

If  symptoms  of  peritonitis  supervene  the  abdomen  should 
be  opened. 

The  treatment  of  fistulse  is  described  later  (p.  523). 

LITERATURE 

Ashurst,  Amer.  Journ.  Med.  Sci.,  July,  1906. 

Bartels,  Arch.  f.  hlin.  Chir.,  1878,  p.  519. 

Berndt,  Arch.  f.  hlin.  Chir.,  1899. 

Blumer,  Brit.  Med.  Journ.,  Dec.  22,  1900. 

Dambrin  et  Papin,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1904,  p.  641. 

Goldenberg,  Beitr.  z.  hlin.  Chir.,  1909,  p.  356. 

Makins,  Surgical  Experiences  in  South  Africa. 

Mitchell,  Ann.  Surg.,  1898,  p.  157. 

Morel,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1906,  p.  801, 

Murray,  Liverpool  Med.- Chir.  Journ.,  1906,  p.  159. 

Quick,  Ann.  Surg.,  1907,  p.  94. 

Seldowitsch,  Arch.  f.  hlin.  Chir.,  1904,  p.  859.     . 

Treves,  Brit.  Med.  Journ.,  1900. 

Wolfer,   Theraf.   Gaz.,  Dec.   15,  1910 


CHAPTER  XXXII 
CYSTITIS 

Etiology. — Inflammation  of  the  bladder  is  due  to  the  combina- 
tion of  a  bacterial  infection  with  some  factor  which  produces 
lowered  resistance. 

An  injury  will  cause  cystitis,  and  repeated  injuries,  such  as 
are  produced  by  the  presence  of  a  stone  in  the  bladder,  will  lead 
to  the  persistence  of  the  cystitis  ;  but  if  the  injury  is  not  repeated 
the  inflammation  is  transient,  and  if  the  cause  of  repeated  in- 
juries (such  as  the  stone)  is  removed  the  cystitis  spontaneously 
disappears.  In  some  cases  the  presence  of  bacteria  of  most  virulent 
type  in  the  urine  without  any  known  local  cause  of  diminished 
resistance  gives  rise  to  cystitis.  On  the  other  hand,  if  bacteria 
reach  the  healthy  bladder  by  the  urethra  or  through  the  kidneys, 
cystitis  is  not  produced  in  the  majority  of  cases.  Urine  which 
is  swarming  with  bacteria  may  be  passed  through  the  bladder 
for  years  without  producing  cystitis.  Pure  cultures  of  bacillus 
coli  and  other  bacteria  have  been  injected  in  experimental  work 
on  animals,  without  producing  cystitis.  When,  however,  the 
penis  has  been  ligatured,  in  addition  to  the  injection  of  bacteria, 
cystitis  is  produced. 

The  predisposing  causes  of  cystitis,  such  as  masturbation, 
affections  of  the  female  genital  organs,  pregnancy,  stricture, 
enlarged  prostate,  calculus,  foreign  bodies,  malignant  growths, 
operations  upon  the  bladder,  atony  from  nervous  disease,  etc., 
may  act  by  producing  congestion  or  injury  to  the  bladder  wall  or 
stagnation  of  the  urine.  They  vary  at  different  ages  and  under 
different  conditions.  In  childhood  and  infancy  cystitis  is  the 
frequent  complication  of  vulvo- vaginitis,  enteritis,  and  stone. 
In  young  men  gonorrhoeal  urethritis  and  stricture,  in  adult 
men  stricture  and  atony  of  the  bladder  from  nervous  disease, 
in  old  men  enlarged  prostate,  in  women  pregnancy  and  diseases 
of  the  uterus  and  ovaries,  are  the  usual  predisposing  causes. 

Bacteriology. — A  large  variety  of  bacteria  are  found  in  the 
urine  in  cystitis,  and  a  mixed  infection  is  frequent.     Cystitis  due 

423 


424  THE  BLADDER  [chap. 

to  the  tubercle  bacillus  will  be  discussed  separately.  The  bacillus 
coli  communis  occurs  more  frequently  than  other  bacteria,  and 
is  often  found  in  pure  culture.  Other  bacteria  that  occur  alone, 
or  in  mixed  infections,  are  the  staphylococcus,  streptococcus, 
proteus,  gonococcus,  the  pneumococcus  of  Fraenkel  and  of  Fried- 
laender,  the  bacillus  pyocyaneus,  and  the  typhoid  bacillus.  In 
chronic  cystitis  anaerobic  bacteria  are  frequently  found.  The 
streptobacillus  fusiformis,  bacillus  ramosus,  micrococcus  fcetidus, 
and  others  may  be  found  alone  or  with  aerobic  bacteria. 

The  bacteriology  of  cystitis  varies  during  the  course  of  an 
attack,  whether  acute  or  chronic.  At  one  time  there  may  be  a 
mixed  infection,  at  another  a  pure  culture.  There  is  a  tendency 
for  certain  bacteria  to  predominate,  while  others  may  be  found 
in  small  numbers  and  have  a  feeble  culture  growth.  When  a 
dominant  bacterium  has  been  reduced  in  virulence  or  destroyed 
by  vaccines,  by  bladder-washing,  or  by  other  means,  other  bacteria 
may  be  found  to  increase  in  numbers.  Thus,  in  a  case  of  almost 
pure  bacillus  coli  cystitis  the  decline  of  this  bacillus  is  not  infre- 
quently marked  by  the  appearance  or  increase  of  staphylococcus. 

The  bacillus  coli  has  a  tendency  to  persist  and  to  dominate 
the  bacteriology  of  a  mixed  infection  ;  the  strepto-  and  staphylo- 
cocci are  readily  displaced  by  other  bacteria,  while  the  pyocyaneus 
tends  to  persist. 

The  urine  remains  acid  in  cystitis  due  to  the  bacillus  coli  and 
the  gonococcus,  and  also  in  about  half  the  cases  of  cystitis  due 
to  bacteria  which  decompose  urea. 

Method  of  infection. — The  bladder  may  be  infected  from  the 
kidney,  the  bacteria  being  borne  by  the  urine.  The  kidney  may 
or  may  not  participate  in  the  inflammation,  and  the  bacteria  are 
usually  blood-borne,  and  in  the  majority  of  cases  bacillus  coli  is 
the  infecting  agent.  Infection  may  be  introduced  by  way  of 
the  urethra  either  by  continuity  of  inflammation  as  in  gonorrhoea 
or  by  the  passage  of  an  instrument.  Bacteria  may  also  reach 
the  bladder  through  a  cystotomy  wound  or  a  fistula,  or  from  the 
rupture  of  an  abscess  or  the  formation  of  a  fistula  with  the  bowel. 

Pathological  anatomy  and  cystoscopic  appearances. — 
Except  in  the  most  severe  varieties  of  cystitis,  little  or  no 
change  is  found  post  mortem.  It  is,  therefore,  necessary  to  take 
advantage  of  the  cystoscope  in  studying  the  appearances  presented 
in  cystitis. 

In  the  majority  of  cases  of  cystitis  the  inflammation  does  not 
affect  the  whole  surface  of  the  bladder  mucous  membrane.  The 
base  is  most  frequently  involved,  while  the  rest  of  the  bladder 
may  escape  ;    less  frequently  there  is  an  area  of  cystitis  at  some 


xxxn]  CYSTOSCOPY   IN    CYSTITIS  425 

pail,  ol  l.lic  orf^an,  soincliiiics  at  the  apex,  while  the  base  is  slightly 
aft'ected.  Occasionally  there  are  patches  ol'  cystitis  distributed 
over  the  bladder.  In  the  more  severe  varieties  of  acute  cystitis, 
and  also  in  chronic  cystitis,  the  whole  of  the  mucous  surface  is 
usually  inflamed.  The  earliest  appearance  of  inflammation  is 
engoigement  of  the  capillary  vessels,  which  appear  as  a  fine  intri- 
cate network.  The  mucous  membrane  becomes  reddened  and 
spongy  or  woolly,  and  the  outline  of  the  vessels  grows  less 
and  less  distinct  until  they  are  completely  obscured.  The  sur- 
face is  now  bright  red,  and  the  mucous  membrane  thrown  into 
stiff  folds  and  ridges,  with  shreds  of  muco-pus  or  desquamated 
epithelium  adhering  to  it.  (Plate  31,  Fig.  1.)  Haemorrhages  may 
occur  into  the  subepithelial  tissues  and  appear  as  dark-red  or 
black  spots  or  blotches  surrounded  by  a  halo  of  intense  inflam- 
mation. If  there  are  numerous  haemorrhages  the  condition  is 
known   as   haemorrhagic  cystitis. 

In  bullous  cystitis  the  surface  is  covered  with  closely-set  yellow 
semitransparent  bullae.  This  appearance  is  usually  confined  to 
some  part  of  the  bladder,  such  as  the  orifice  of  a  diverticulum, 
the  neighbourhood  of  the  ureter  in  a  virulent  descending  inflam- 
mation, or  the  area  arCund  a  malignant  growth,  or  it  may  extend 
over  the  whole  base.  It  may  be  quite  evanescent.  Small,  closely 
grouped  granules  in  the  inflamed  mucous  membrane  are  character- 
istic of  follicular  cystitis. 

In  cystic  cystitis  there  are  yellow  sago-grain-like  follicles  which 
may  be  scattered  or  grouped  together,  and  may  be  surrounded 
by  a  halo  of  inflammation,  or  by  only  a  few  injected  vessels. 
(Plate  31,  Fig.  2.)  Groups  of  small  cysts  may  form  in  inflamed 
areas  and  project  from  the  surface  in  masses  like  bunches  of  grapes, 
or  there  may  be  solid  projecting  masses.  In  these  cases  there 
may  be  cysts  in  the  ureter  and  renal  pelvis.  Stoerk  and  Zucker- 
kandl  have  found  that  the  cysts  result  from  the  closure  of  the 
orifices  of  small  invaginations  of  epithelium,  or  by  the  fusion  of 
papillary  excrescences  on  the  surface.  Adeno-carcinoma  may  take 
origin  in  these  cysts. 

Extensive  deposit  of  phosphatic  salts  may  take  place  in  patches, 
along  the  ridges  of  inflamed  mucous  membrane  or  over  large  areas 
of  the  bladder.  This  may  be  heaped  up  into  irregular  projecting 
masses. 

Necrosis  of  the  superficial  layers  of  mucous  membrane  mixed 
with  fibrin  forms  a  membrane  which  is  cast  off,  and  the  con- 
dition is  named  croupous  or  diphtheritic  cystitis.  The  infection 
in  these  cases  is  usually  streptococcal. 

In  very  virulent  infections  exfoliation  of  the  bladder  mucous 


426  THE   BLADDER  [chap. 

membrane  may  take  place,  and  the  necrosed  membrane  is  passed 
as  a  cast  of  the  bladder.  Emphysema  of  the  mucous  membrane 
has  been  described. 

Ulceration  is  usually  confined  to  the  superficial  layers.  It  is 
frequently  found  along  the  summit  of  ridges  and  folds,  and  may 
extend  more  widely.  Less  frequently  there  is  a  circumscribed 
deep  round  or  oval  ulcer,  with  a  heaped-up,  sharply  defined  edge. 
(Plate  31,  Fig.  3.)  I  have  also  seen  a  spreading  ring-like  ulcer 
commencing  at  the  apex  and  advancing  to  the  base. 

Leucoplakia  is  found  in  stone  and  other  conditions  of  chronic 
irritation,  and  there  may  be  a  single  patch  or  several  patches. 
The  surface  is  dry,  greyish  or  yellowish  white,  and  parchment- 
like. The  edges  are  irregular,  and  the  surrounding  mucous  mem- 
brane is  deep  red  and  intensely  inflamed. 

The  epithelium  becomes  transformed  into  squamous  epithelium, 
which  is  heaped  up  in  thick  masses.  In  chronic  cystitis  there  are 
infiltration  and  sclerosis  of  the  submucous  tissue  and  muscular 
layer,  and  a  great  increase  in  the  perivascular  fat,  which  becomes 
fibrous  and  adherent.  The  bladder  becomes  contracted  and  the 
cavity  permanently  diminished. 

When  cystitis  complicates  urethral  obstruction  there  is  thicken- 
ing of  the  bladder  wall  from  hypertrophy  of  the  muscle. 

In  stricture,  trabeculation  is  always  less  marked  and  saccu- 
lation less  pronounced  than  in  enlarged  prostate.  In  the  latter, 
sacculation  with  thinning  and  atrophy  of  the  muscular  layer  is 
frequently  present.  Calculi  often  form  in  the  bladder  in  chronic 
cystitis,  especially  when  there  are  sacculi  or  residual  urine. 

Symptoms. — The  symptoms  of  cystitis  are  frequent  micturi- 
tion, pain,  and  changes  in  the  urine. 

Increased  frequency  of  micturition  usually  draws  attention 
to  the  condition.  The  frequency  varies  with  the  intensity  of  the 
cystitis.  In  slight  cases  the  urine  may  be  passed  every  two  hours, 
and  there  is  some  urgency  when  the  call  to  micturate  is  felt.  In 
severe  cases  a  few  drops  of  urine  are  passed  every  few  minutes, 
and  necessity  to  pass  water  is  uncontrollable,  so  that  a  form  of 
active  incontinence  is  produced.  In  the  lesser  grades  the  patient 
sleeps  throughout  the  night,  but  in  severe  cystitis  the  call  to  mic- 
turate is  powerful  and  frequent  during  the  night  as  well  as  the 
day.  The  bladder  may  be  so  sensitive  that  spasm  is  induced 
by  jarring  the  bed,  or  a  breath  of  cold  air,  or  a  hot  or  cold  drink. 
Polyuria  frequently  accompanies  the  frequent  micturition,  and 
is  said  to  be  due  to  a  reflex  influence  on  the  kidney.  It  diminishes 
as  the  frequency  subsides. 

Pain  is  present  to  a  varying  degree.     There  is  scalding  pain 


Fig.  1. — Acute  cystitis.  (P.  425.) 
Fig,  2.— Cystic  cystitis.  (P.  425.) 
Fig.  3. — Ulcer  of  bladder  in  cystitis  due  to  Bacillus  coli 

communis.     (P.  426.) 
Fig.  4. — Tuberculosis     of    bladder ;      group     of    caseous 

tubercles.     (P.  439.) 
Fig.  5. — Tuberculous     ulcer     of     bladder     with     caseous 

tubercles  in  vicinity.     (P.  439.) 

Plate  31. 


xxxn]  CYSTITIS:    SYMPTOMS  427 

aloii!^  lilic  iiicl.Iira  on  passiiiif  wat.cr,  and  inl.ciisc  desire  and  pain 
when  au  at.tein])t  is  made  to  hold  the  urine.  In  niodenitely  scivere 
cases  there  is  diseonilort  at  the  end  of  micturition,  and  a  feeling 
that  the  bladder  has  not  been  emptied;  and  in  severe  cases  a 
cramping  pain  at  the  neck  of  the  bladder,  in  the  rectum,  along 
the  urethia  to  the  end  of  the  penis,  and  sometimes  radiating  down 
the  thighs. 

Pyuria  is  always  present,  but  varies  greatly  in  amount.  The 
pus  is  mixed  with  mucus  in  varying  proportion.  It  may  form  a 
haze  which  settles  to  the  bottom  of  a  glass  as  a  billowy  semitrans- 
lucent  mass,  or  in  more  severe  or  chronic  cases  it  forms  a  slimy 
tenacious  deposit  which  clings  to  the  bottom  of  the  receptacle. 
The  quantity  of  mucus  and  pus  is  not  subject  to  sudden  variation 
unless  the  cystitis  is  complicated  by  sacculation  or  diverticula 
of  the  bladder,  pyelitis,  or  some  other  disease  which  permits  of 
accumulation  and  sudden  discharge  of  pus.  The  urine  is  mixed 
with  blood  in  severe  cases  ;  in  less  severe  cases  there  may  be 
terminal  hsematuria.  In  most  cases  no  blood  is  seen  with  the 
naked  eye,  but  very  frequently  blood  corpuscles  are  found  with 
the  microscope  in  the  acute  stage. 

Fever  is  not  present  unless  cystitis  is  complicated  by  renal, 
prostatic,  or  some  extravesical  inflammation.  There  is  tender- 
ness on  pressure  above  the  pubes  and  on  rectal  and  vaginal  exam- 
ination. The  bladder  wall  can  be  felt  from  the  rectum  thickened 
and  contracted.  The  capacity  of  the  bladder  is  reduced  to  a 
degree  corresponding  to  the  intensity  of  the  inflammation.  In 
acute  cystitis  the  bladder  may  not  retain  more  than  |^  oz.  of  fluid ; 
in  less  acute  cystitis  the  organ  may  hold  1  oz.  or  several  ounces. 

Cystoscopy  is  difficult  and  may  be  impossible  in  acute  cystitis, 
and  it  is  advisable  to  wait  until  the  acute  stage  has  passed  before 
using  the  cystoscopy  There  is  difficulty  in  obtaining  adequate 
distension  of  the  organ  or  a  medium  clear  of  pus  and  blood. 
Cystoscopy  shows  that  in  a  large  proportion  of  cases  of  cystitis 
the  inflammation  affects  a  small  area  of  the  bladder,  usually 
at  the  base.  When  the  inflammation  is  descending  and  mild,  an 
area  surrounding  one  ureter  and  involving  the  trigone  is  alone 
affected ;  when  inflammation  has  reached  the  bladder  by  ex- 
tension from  the  urethra  (urethro-cystitis)  the  trigone  is  most 
acutely  inflamed.  In  other  cases  cystitis  consists  of  scattered 
patches  of  inflammation  over  the  mucous  surface  or  of  an  inflamed 
area  at  the  apex  or  elsewhere. 

The  illumination  is  more  difficult  in  cystitis  than  in  a  normal 
bladder,  for  the  reflecting  property  of  the  mucous  membrane 
is  diminished  by  desquamation  of  the  surface  epithelium. 


428  THE   BLADDER  [chap. 

The    appearances    seen    on    cystoscopy    have     already  •  been 

described  (p.  424). 

/      Complications. — Retention  of  urine  may  occur  as  a  compH- 

/  cation  of  cystitis,  usually  in  cases  of  stricture  of  the  urethra  or 

of  enlarged  prostate,  but  also  in  atony  of  the  bladder  from  neryous" 

disease.     Ascending  infection  of  the  kidneys  is  a  (.onstant  danger, 

V especially  wFeii' obstnrciroFTi''^present,  and  is  the  cause  of  "dSa^ 
in  most  of  the  fatal  cases  of  cystitis.  —- 

""""Abscess  of  the  wall  of  the  bladder,  or  surrounding  a  saccule, 
or  in  the  perivesical  tissue,  may  complicate  chronic  cystitis. 

Diagfnosis. — The  diagnosis  of  cystitis  involves  a  number  of 
questions  : 

1.  Are  the  symptoms  due  to  cystitis  or  to  some  con- 
dition outside  the  bladder?  (a)  Extra-urinary  causes  of  vesical 
symptoms. — Pain  in  the  bladder  of  a  dull  constant  aching  char- 
acter, sometimes  also  in  acute  attacks,  may  occur  in  tabes,  and 
reflex  pain  is  observed  in,  cases  of  haemorrhoids  and  anal  fissure, 
and  there  is  a  condition  known  as  "  neuralgia  "  of  the  bladder  in 
which  pain  is  present  without  recognizable  cause.  In  these  con- 
ditions there  is  pain  but  no  pyuria. 

Frequent  micturition  may  also  be  caused  by  extravesical  con- 
ditions, such  as  pregnancy,  ovarian  or  fibroid  tumours,  prolapse 
of  the  uterus.     Here  also  pyuria  is  absent. 

(b)  Urinary  causes  of  vesical  symptoms  without  cystitis. — 
Frequent  micturition  may  be  due  to  the  passage  of  large  quan- 
tities of  urine  in  diabetes  mellitus,  diabetes  insipidus,  hysterical 
polyuria,  etc.  In  such  cases  pain  is  usually  absent,  but  there 
may  be  dull  aching  vesical  pain. 

In  highly  acid  urines  and  urines  containing  oxalate  crystals, 
and  in  phosphaturia,  frequent  and  urgent  micturition  with  pain 
is  often  present.  The  condition  of  the  urine,  the  absence  of  pus, 
and  the  effect  of  treatment  distinguish  these  cases. 

Occasionally  frequent  micturition  due  to  urethral  obstruction 
in  stricture  may  be  ascribed  to  the  effect  of  the  obstruction 
on  a  sensitive  bladder,  apart  from  cystitis. 

In  enlarged  prostate  frequent  micturition  is  an  early  and  pro- 
minent symptom  when  no  cystitis  is  present.  This  is  due  partly 
to  the  pressure  of  the  enlarging  prostate  on  the  base  and  sphincter 
of  the  bladder,  and  partly  to  the  exposure  to  the  urine  in  the 
bladder  of  the  sensitive  mucous  membrane  of  the  prostatic  urethra, 
which  is  dragged  up  through  the  vesical  sphincter  by  the  intra- - 
vesical  projection  of  the  prostate. 

Urethral  polypi  in  the  male  or  female  urethra  may  cause  fre- 
quent painful  micturition.     Reflex  bladder  pain  and  frequency  of 


xxxn]    PRIMARY  AND  SECONDARY  CYSTITIS     12') 

micturition  are  coininoii  in  coitaiii  diseases  of  the  kidney,  notably 
in  tuberculous  disease,  calculus,  and  pyelitis.  In  these  cases  the 
ureter  of  one  side  may  show  congestion  and  other  slight  changes, 
and  the  trigone  be  infected,  but  usually  no  changes  referable  to 
cystitis  can  be  found  in  the  bladder.  In  pyelitis  the  frequency  is 
principally  nocturnal.  The  diagnosis  is  made  by  the  discovery  of 
pus  and  bacteria  in  the  urine  and  by  the  use  of  the  cystoscope. 

2.  Is  the  cystitis  primary  or  secondary  ? — This  question 
only  applies  to  the  condition  at  the  time  of  the  examination,  for 
the  bladder  is  an  internal  organ  at  which  bacteria  arrive  by  the 
urethra,  the  ureter,  or  the  blood  stream,  or  from  the  bursting  of 
an  abscess  through  the  bladder  wall ;  and  primary  infection  in 
the  strict  sense  only  occurs  in  cystotomy  or  other  wounds  of  the 
bladder. 

In  a  secondary  cystitis  the  removal  of  the  primary  extravesical 
focus  is  followed  by  disappearance  of  the  cystitis. 

The  bladder  may  be  infected  from  the  kidney  in  cases  of  renal 
calculus,  pyonephrosis,  pyelonephritis,  renal  tuberculosis,  etc., 
or  there  may  be  infection  from  the  urethra  (urethro-cystitis)  in 
acute,  subacute,  or  chronic  urethritis.  The  source  of  infection  in 
subacute  and  chronic  -cases  is  the  prostatic  urethra,  and  there 
is  usually  chronic  prostatitis  as  well. 

In  renal  suppuration  there  may  be  symptoms  of  disease  of 
the  kidney,  such  as  pain,  tenderness,  enlargement  of  the  kidney ; 
and  if  no  cystitis  is  present,  tenderness  of  the  bladder  and  pain 
on  distension  with  fluid  are  absent.  The  urine  sometimes  con- 
tains cells  from  the  renal  pelvis,  and  tubules,  and  occasionally  tube 
casts,  while  vesical  epithelium  is  absent.  The  reaction  of  the 
urine  in  renal  affections  is  usually  acid  from  the  blending  of  acid 
urine  from  the  second  kidney ;  but  this  is  not  a  reliable  point  in 
diagnosis,  for  the  urine  may  be  alkaline  in  renal  disease  and  acid 
in  some  forms  of  cystitis.  The  pus  in  pyelitis  or  pyelonephritis, 
and  especially  in  pyonephrosis,  is  greater  in  quantity  than  in 
cystitis,  and  forms  a  heavy,  flat  layer  at  the  bottom  of  the  glass  ; 
and  it  is  liable  to  sudden  and  marked  variations  in  quantity.  In 
cystitis  the  pus  is  mixed  with  mucus,  and  forms  an  irregular 
deposit  which  is  slimy  and  tenacious.  Variations  in  quantity  do 
not  occur.  When  cystitis  complicates  suppurative  renal  disease, 
the  combination  of  a  heavy  substratum  of  pus  with  an  upper 
layer  of  muco-pus  is  observed. 

The  diagnosis  of  cystitis  secondary  to  renal  disease  is  made 
by  the  cystoscopic  inspection  of  the  ureteric  orifices.  The  inflam- 
matory area  may  surround  one  ureter,  or  it  may  affect  the  whole 
bladder  surface.     The   orifice   shows   inflammatory   changes,   and 


430  THE   BLADDER  [chap. 

the  efflux  is  purulent.  In  slight  cases  the  ureteral  catheter  may 
be  necessary  to  ascertain  the  origin  of  the  infection. 

In  urethro-cystitis  there  are  signs  of  urethral  inflammation, 
and  the  use  of  the  urethroscope  and  cystoscope  confirms  the 
diagnosis.  Entero-vesical  fistula  may  be  the  cause  of  acute 
cystitis,  and  of  chronic  cystitis  with  acute  exacerbations.  The 
diagnosis  is  made  by  examination  of  the  urine  and  by  cystoscopy. 

3.  In  primary  cystitis,  what  is  the  cause  ? — Acute  sponta- 
neous cystitis  is  most  frequently  due  to  the  bacillus  coli,  but  also 
to  other  bacteria.  Subacute  and  chronic  cystitis  may  be  purely 
bacterial,  or  there  may  be  a  diverticulum,  stone,  or  growth  of  the 
bladder  with  secondary  infection.  Of  cases  of  malignant  growth 
of  the  bladder,  40  per  cent,  come  under  observation  as  cases  of 
chronic  spontaneous  cystitis.  The  urine  in  all  subacute  chronic 
cases  should  be  carefully  examined  bacteriologically  and  histo- 
logically, and  the  bladder  inspected  with  the  cystoscope. 

Prognosis. — In  acute  cystitis  without  complications  the  prog- 
nosis is  good.  The  attack  lasts  from  two  to  four  or  five  weeks, 
and,  if  there  is  no  focus  of  recurrent  infection  inside  the  bladder, 
recovery  is  usually  complete.  When  a  diverticulum  or  sacculi 
of  the  bladder  are  present,  recurrent  attacks,  and  eventually 
chronic  cystitis,  may  be  expected. 

Cystitis  complicated  by  urethral  obstruction  rarely  disappears 
unless  the  obstruction  is  completely  removed.  Cystitis  in  an 
atonic  bladder  in  nervous  disease  usually  becomes  permanently 
established,  and  the  chronic  inflammation  is  subject  to  acute 
exacerbations  from  time  to  time,  usually  as  the  result  of  infection 
from  outside  sources.  When  suppuration  in  the  kidney  is  the 
primary  disease  and  cystitis  is  secondary,  the  latter  will  not  be 
relieved  until  the  renal  infection  is  removed. 

Ascending  pyelonephritis  is  the  flnal  stage  of  most  of  the  fatal 
cases  of  cystitis.  The  infection  may  ascend  spontaneously  or 
may  follow  upon  bladder-washing. 

Treatment.  Acute  cystitis. — In  acute  cystitis  the  patient 
should  be  confined  to  bed  and  treatment  chiefly  directed  to  sooth- 
ing the  inflamed  bladder.  The  diet  should  consist  mainly  of 
milk,  eggs,  custards,  soups,  and  light  farinaceous  foods.  Alcohol 
should  be  interdicted.  Diuretics  such  as  Contrexeville,  Vittel, 
Vichy,  and  Evian  waters,  barley  water,  buchu  and  parsley  tea 
are  administered  to  render  the  urine  less  irritating.  When  the 
urine  is  acid  the  administration  of  alkalis  is  of  great  value.  Citrate 
of  potash  20  gr.,  pot.  bicarb.  20  gr.,  magnesium  sulphate  30-60  gr., 
and  liquor  potassae  5  minims,  may  be  given,  and  sandalwood  oil 
has  a  soothing  eft'ect   (10  minims  in  capsule  or  emulsion).     To 


XXXII]  CYSTITIS:    TREATMENT  431 

reduce  the  painful  spasm  of  the  bladder  the  following  are  useful, 
viz. :  tincture  of  belladonna  5  or  10  minims,  tincture  of  hyoscyamus 
15  minims,  tincture  of  opium  5-15  minims,  and  bromide  of  cam- 
phor 5  gr.,  by  the  mouth ;  and  lupulin  4  gr.,  extract  of  belladonna 
J  gr.,  and  morphia  l-^  gr.,  given  singly  or  in  combination  as  sup- 
pository, and  repeated  twice  or  thrice  in  the  twenty-four  hours 
provided  morphia  and  belladonna  are  not  being  administered  by 
the  mouth.  Hot  sitz-baths  are  given  twice  or  thrice  a  day,  the 
patient  being  well  covered  up  during  the  bath,  which  lasts  for 
ten  or  twenty  minutes,  and  thoroughly  rubbed  down  afterwards. 
Hot  fomentations,  to  which  laudanum  may  be  added,  are  applied 
to  the  lower  abdomen  and  perineum,  and  when  intense  strangury 
is  present  a  small  enema  of  hot  water  containing  antipyrin  20-30  gr., 
or  a  vaginal  douche  of  similar  composition,  may  be  given.  Two 
teaspoonfuls  of  starch  and  15  or  30  minims  of  tincture  of  opium 
may  be  added  to  the  enema. 

Occasionally  a  hypodermic  injection  of  morphia  J  gr.  with 
atropine  jljy  gr.  may  be  necessary. 

The  bowels  should  be  freely  opened  by  a  smart  saline  purge, 
and  a  daily  aperient  such  as  Apenta,  Hunyadi  Janos,  or  cascara 
given.  No  attempt  should  be  made  to  wash  the  bladder  at  this 
stage.  In  very  painful  cystitis  an  instillation  of  a  few  drachms 
or  ounces  of  distilled  water  containing  antipyrin  2  per  cent.,  and 
laudanum  |  to  1  per  cent.,  or  of  orthoform  5  to  10  per  cent.,  in 
oil,  may  be  cautiously  introduced. 

Subacute  cystitis. — The  acute  stage  lasts  from  three  to  ten 
days,  and  is  followed  by  a  subacute  stage.  In  subacute  cystitis 
the  patient  may  be  allowed  up  and  a  less  restricted  diet  per- 
mitted, but  all  highly  spiced  foods,  cm'ries,  much  meat,  coffee, 
and  all  alcoholic  drinks  are  forbidden. 

Urinary  antiseptics  should  be  administered  by  the  mouth, 
such  as  urotropine,  hetralin,  or  helmitol  10  gr.  of  each,  urodonal 
1  drachm,  and  salol  5-15  gr.  ;  and  sometimes  benzoate  of 
soda  or  ammonia  10  gr.,  and  boric  acid  15  gr.,  will  be  found 
valuable. 

If  the  cystitis  is  due  to  the  bacillus  coli  or  to  other  bacteria 
which  flourish  in  an  acid  urine,  alkalis  should  be  given.  If,  on 
the  other  hand,  the  urine  becomes  alkaline  from  ammoniacal 
decomposition  owing  to  the  presence  of  the  bacillus  ureae  lique- 
faciens  in  mixed  infections,  alkalis  should  be  withheld,  and  dilute 
mineral  acids,  benzoate  of  soda  and  ammonia,  and  boric  acid 
given.  Sodium  acid  phosphate  20-30  gr.  is  especially  useful, 
together  with  large  doses  of  urotropine  or  other  urinary  antiseptics. 
Bladder-washing  should  be  commenced  when  the  acute  symptoms 


432  THE   BLADDER  [chap. 

have  passed  off.  Vaccine  treatment  with  an  autogenous  vaccine 
will  be  found  of  use  in  this  stage. 

Chronic  cystitis. — In  chronic  cystitis  a  very  careful  examina- 
tion with  the  cystoscope  is  necessary  to  ascertain  whether  there 
is  some  factor  such  as  renal  suppuration,  stone,  enlarged  prostate, 
or  diverticula  which  may  act  as  a  contributory  cause  and  prevent 
resolution  of  the  cystitis.  Should  any  such  complication  be  present 
it  must  be  dealt  with  before  the  cystitis  can  be  cured. 

The  treatment  is  similar  to  that  of  subacute  cystitis.  The 
only  restrictions  of  diet  that  are  necessary  are  the  avoidance  of 
articles  such  as  curries  and  all  highly  spiced  foods  and  alcohol. 
Alkalis  or  acids  and  urinary  antiseptics  are  administered  as  in 
subacute  cystitis. 

Bladder-washing  plays  a  prominent  part  in  the  treatment ;  a 
visit  to  one  of  the  Continental  spas,  such  as  Wildungen,  Contrexe- 
ville,  or  Vittel,  is  frequently  of  great  service.  Vaccine  treatment 
is  occasionally  beneficial,  while  drainage  of  the  bladder  with  daily 
flushing  or  continuous  irrigation  may  become  necessary. 

Bladder-washing. — This  is  suitable  for  subacute  or  chronic 
cystitis.  A  large  rubber  or  silk-wove  coude  catheter  with  a 
trumpet-shaped  outer  end  is  sterilized  and  carefully  passed  into 
the  bladder.  An  irrigating  can  hung  2  or  3  ft.  above  the  level  of 
the  recumbent  patient  contains  the  solution  selected,  the  tempera- 
ture of  which  is  about  100°  F.  A  glass  bladder  syringe  with  metal 
fittings  and  asbestos  plunger  may  be  used  to  replace  the  irrigator. 
The  fluid  is  allowed  to  flow  through  the  catheter  slowly  until  the 
patient  begins  to  feel  slight  discomfort,  when  the  nozzle  is  removed 
and  the  fluid  run  off.  Several  pints  of  solution  are  used  in  this 
way,  and  the  mechanical  action  of  free  washing  with  large  volumes 
of  fluid  plays  an  important  part. 

A  double-way  catheter  does  not  wash  the  bladder  so  thoroughly 
as  a  single-bore  instrument. 

In  some  cases  masses  of  tenacious  muco-pus  adhere  to  the 
bladder  wall  or  obstruct  the  lumen  of  the  catheter.  In  acid  cystitis 
a  preliminary  washing  with  a  weak  alkali  such  as  bicarbonate  of 
soda,  1  or  2  per  cent.,  is  useful,  while  in  very  alkaline  cystitis  with 
deposit  of  phosphates  I  have  found  much  benefit  from  the  use 
of  a  weak  solution  of  acetic  acid,  ^  per  cent.  Solutions  that  may 
be  used  for  washing  the  bladder  are  potassium  permanganate 
1  in  5,000  or  10,000,  oxycyanide  of  mercury  1  in  1,000  or  5,000, 
biniodide  of  mercury  1  in  10,000  or  20,000,  tincture  of  iodine 
i-1  drachm  to  the  pint,  nitrate  of  silver  1  in  10,000  or  20,000, 
peroxide  of  hydrogen  1  in  10  or  1  in  20  of  the  twenty  volumes, 
lysol  |-1  per  cent.,  protargol  |  per  cent. 


xxxii]  DRAINAGE    IN    CYSTITIS  433 

Instillations. — The  instillation  of  small  quantities  (-|-2 
drachms)  of  more  powerful  solutions  is  sometimes  useful.  These 
are  introduced  by  means  of  a  small  syringe  and  catheter  such 
as  Gruyon's  syringe.  Iodoform  in  sterilized  liquid  paraffin  (5  per 
cent.)  is  a  useful  solution  ;  the  oil  floats  in  the  urine,  and,  if  the 
patient  is  careful  to  stop  micturition  before  he  has  completely 
emptied  his  bladder,  some  of  the  solution  may  be  retained  in 
the  bladder  for  several  days.  Gomenol  is  analgesic  as  well  as 
antiseptic  ;  it  is  used  in  oil  solutions  of  5  to  20  per  cent.,  and 
may  also  be  given  internally  in  capsule.  Silver  nitrate  2  per 
cent.,  protargol  2  per  cent.,  and  acid  picric  |-1  per  cent.,  may 
also  be  used.  In  chronic  alkaline  cystitis  instillations  of  lactic 
acid  bacillus  in  the  form  of  trilactine  may  be  beneficial.  I  have 
instilled  ^-1  drachm  of  freshly  prepared  trilactine  daily  after 
washing  the  bladder  with  sterile  water,  with  marked  improvement 
in  the  condition  of  the  urine. 

Bladder  drainage. — Drainage  of  the  bladder  is  very  excep- 
tionally required  in  acute  cystitis,  and  then  only  in  the  rare  cases 
of  fulminating  cystitis  with  sloughing  of  the  mucous  membrane. 
It  is  chiefly  of  use  in  intractable  subacute  or  chronic  cystitis,  and 
may  be  carried  out  through  the  urethra,  or  by  the  perineal  or 
the  suprapubic  route. 

In  urethral  drainage  a  catheter  is  "  tied  in."  A  silk-wove 
coude  catheter  (No.  10  Fr.),  a  Jacques  rubber  catheter,  or  a 
Pezzer's  self-retaining  rubber  catheter  is  used.  In  the  female 
subject  the  last  is  most  suitable,  and  is  introduced  with  a 
stilette. 

In  the  male  subject  the  catheter  is  passed  until  the  eye  is  just 
within  the  internal  meatus,  and  its  position  is  tested  by  injecting 
a  little  fluid  with  a  syringe  and  allowing  it  to  flow  off,  gradually 
withdrawing  the  catheter  until  the  flow  becomes  arrested,  and 
then  pushing  the  catheter  in  again  until  the  flow  is  re-established. 
Two  strands  of  silk  or  two  short  strips  of  narrow  tape  are  tied 
firmly  around  the  catheter,  without  constricting  its  lumen,  ^  in. 
beyond  the  external  meatus,  and  if  there  is  any  tendency  for 
them  to  slip  a  small  safety-pin  is  oiled  and  passed  through  the 
tape  and  catheter  at  this  point. 

The  four  tails  of  silk  or  tape  are  laid  along  the  penis,  and  a 
strip  of  adhesive  plaster  1  in.  broad  is  wound  round  the  penis 
over  these,  just  behind  the  corona  glandis,  care  being  taken  not 
to  apply  it  so  tight  as  to  cause  constriction.  The  ends  of  the 
tape  may  be  turned  back  under  a  second  round  of  plaster.  The 
adhesive  plaster  may  be  applied  longitudinally  to  avoid  causing 
oedema  of  the  foreskin.  A  short  length  of  rubber  tubing  is  attached 
2c 


434  THE   BLADDER  [cHAr. 

to  the  end  of  the  catheter  and  carried  into  a  bottle  between  the 
patient's  thighs.  If  the  catheter  becomes  blocked,  this  may  be 
due  to  tenacious  mucus  or  blood  clot,  or  to  gravel,  or  there  may 
be  a  kink  of  a  silk-wove  catheter,  or  the  instrument  may  have 
sHpped  so  that  the  eye  is  in  the  urethra. 

Perineal  drainage  is  carried  out  by  opening  the  membranous 
urethra  on  a  staff  by  a  median  incision  and  introducing  a  rubber 
perineal  drainage  tube  through  the  prostatic  portion  of  the  urethra 
into  the  bladder.  A  stitch  through  the  edges  of  the  wound  fixes 
the  tube,  and  a  length  of  tubing  carries  the  urine  into  a  vessel. 

When  a  stiff  gum-elastic  tube  is  used,  metal  loops  are  provided 
for  perineal  tapes  passing  anteriorly  in  the  fold  of  the  groin  and 
posteriorly  in  the  fold  of  the  buttock  to  a  waist-band.  The  mor- 
tality of  this  operation  is  high — 25  per  cent. — as  it  is  frequently 
practised  in  severe  cases,  and  often  at  a  late  stage. 

Suprapuhic  drainage  is  carried  out  by  distending  the  bladder 
with  fluid  and  opening  it  by  a  vertical  median  suprapubic  incision. 
The  bladder  should  be  thoroughly  explored,  and  any  cause  for 
the  persistence  of  the  cystitis  ascertained  and,  if  possible,  removed. 
In  the  case  of  a  middle-aged  woman  whose  bladder  was  encrusted 
with  phosphatic  deposit  heaped  up  in  parts  so  as  to  resemble  a 
large  phosphate-covered  growth,  I  applied  pure  acetic  acid  to  the 
interior,  and  afterwards  washed  the  bladder  with  a  weak  solution 
of  acetic  acid  for  a  fortnight.  The  recovery  from  a  long-standing 
and  intractable  cystitis  was  rapid  and  uninterrupted. 

A  large  rubber  drainage  tube  (f-1  in.  diameter)  is  introduced, 
and  the  bladder  wound  closed  around  this  with  catgut  stitches. 
A  smaller  tube  is  placed  in  the  prevesical  space.  Both  tubes  are 
removed  on  the  fourth  day,  and  a  smaller  tube  is  introduced  into 
the  bladder.  An  alternative  method  is  to  stitch  the  edge  of  the 
bladder  wound  to  the  skin,  but  there  is  often  diflficulty  in  obtaining 
healing  later  and  a  fistula  persists. 

The  mortality  of  suprapubic  drainage  is  10  per  cent.  (Joubert). 
In  the  female  subject  a  fistula  may  be  created  between  the  bladder 
and  the  vagina  for  the  purpose  of  draining  the  bladder.  This  is 
frequently  successful  in  curing  cystitis,  but  a  fistula  remains  in 
50  per  cent,  of  cases. 

Comparative  value  of  methods. — Urethral  bladder  drainage  may 
suffice,  but  it  is  less  thorough  than  either  of  the  other  methods. 

Suprapubic  drainage  is  preferable  to  perineal  unless  there  is 
a  stricture  of  the  urethra,  when  perineal  drainage  can  be  com- 
bined with  external  urethrotomy.  In  other  cases  the  bladder  can 
be  more  thoroughly  explored  by  the  suprapubic  route,  and  drain- 
age and  washing  can  be  more  easily  carried  out.     The  perineal 


XXXII]  VACCINES    IN    CYSTITIS  435 

tube  does  not  drain  the  lowest  part  of  the  bladder,  since  the  end 
of  the  tube  projects  into  the  bladder  at  the  internal  meatus,  which 
is  the  highest  part  of  the  fixed  portion  of  the  bladder  when  the 
patient  lies  on  his  back.  The  suprapubic  drainage  tube  passes 
to  the  bottom  of  the  bladder,  and  this  part  is  more  readily  drained 
and  washed. 

Continuous  irrigation. — This  is  carried  out  by  the  supra- 
pubic route,  and  can  conveniently  be  arranged  by  using  an  Irving 
suprapubic  drainage  apparatus.  Through  the  small  hole  in  the  lid 
of  the  apparatus  a  rubber  catheter  passes,  and  descends  through 
the  rubber  tube  in  the  suprapubic  wound  to  the  lowest  part  of 
the  bladder.  To  the  outer  end  of  this  catheter  rubber  tubing  is 
attached,  and  leads  from  a  reservoir  placed  above  the  level  of 
the  patient.  The  flow  is  regulated  by  screw  clips  so  as  to  allow 
of  a  gentle  continuous  stream,  and  arrangements  must  be  made 
for  keeping  the  fluid  in  the  reservoir  warm. 

Serum  and  vaccine  treatment. — Serum-thera'py  consists  in 
supplying  the  patient  with  antibodies  contained  in  the  serum  of 
an  animal  artificially  immunized  by  inoculation  with  bacteria. 
In  acute  cystitis  this  method  may  be  useful.  Antistreptococcic 
serum  is  obtained  from  animals  inoculated  either  with  one  strain 
of  streptococcus  or  with  several  strains  from  different  sources  (poly- 
valent). Anti-colon-bacillus  serum  has  not  yet  been  widely  used. 
The  serum  is  injected  subcutaneously,  and  a  large  initial  dose 
(20  c.c.)  is  given,  followed  by  smaller  doses  (10  c.c).  Calcium 
lactate  should  be  given  at  the  same  time  as  the  serum  in  order 
to  prevent  serum  rashes  and  joint  troubles.  Care  must  be  taken 
not  to  continue  the  treatment  too  long,  lest  the  state  of  hyper- 
sensitiveness  to  the  serum,  known  as  anaphylaxis,  be  produced. 

Vaccine  treatment  is  most  suitable  for  cases  of  subacute  and 
chronic  cystitis.  It  consists  in  the  inoculation  of  the  patient  with 
graduated  doses  of  vaccine  with  the  object  of  increasing  the  resist- 
ance to  the  special  bacteria  by  the  production  of  antibodies.  The 
vaccine  should  be  prepared  from  cultures  of  the  patient's  urine. 
Stock  vaccines  are  of  much  less  value.  The  bacteriology  of  the 
urine  is  investigated,  and  if  the  infection  is  by  a  pure  culture  a 
vaccine  from  that  strain  is  obtained.  If  several  varieties  of  bac- 
teria are  present  the  dominant  species  is  selected,  or  if  more  than 
one  grows  luxuriantly  a  mixed  vaccine  is  prepared.  The  vaccine 
consists  of  a  measured  number  of  the  bacteria  sterilized. 

For  a  period  of  forty-eight  hours  after  the  inoculation  the 
resistance  of  the  patient  is  lowered  (negative  phase),  and  then  it 
rises,  and  remains  high  for  several  days,  falling  again  to  its  previous 
level  or  a  little  above  it.     For  the  earlier  inoculation  it  is  often 


436  THE  BLADDER  [chap,  xxxii 

necessary  to  examine  the  opsonic  index,  so  that  too  large  a  dose 
may  not  be  given  and  a  second  dose  may  not  encroach  upon  the 
negative  phase  of  a  previous  inoculation.  In  the  majority  of 
cases,  however,  it  is  possible  to  dispense  entirely  with  this  exam- 
ination, and  to  rely  upon  experience  and  clinical  observation  as 
guides  to  dosage.  The  inoculations  should  begin  with  small  doses 
at  intervals  of  three  or  four  days,- the  doses  rising  continuously, 
and  the  interval  being  extended  to  a  week  or  longer.  The  more 
acute  the  disease  the  smaller  the  dose  of  vaccine.  If  possible^ 
a  reaction  should  be  avoided.  It  is  shown  by  a  feeling  of  malaise, 
pains  in  the  back  and  head,  and  a  slight  rise  of  temperature,  with 
increased  irritability  of  the  bladder.  The  most  frequently  used 
vaccine  is  that  of  the  bacillus  coli,  and  this  may  be  employed 
alone  when  the  culture  is  pure,  or  in  combination  with  other 
vaccines  when  it  is  mixed.  The  inoculations  can  usually  be 
commenced  with  a  dose  of  3  milUons  given  every  three  or  four 
days,  the  dose  being  raised  to  4  and  5  millions  with  extension  of 
the  interval  to  a  week,  and  then  to  10,  15,  20,  30,  40,  50,  60,  80, 
100,  150,  and  eventually  to  200  millions,  and  even  higher.  The 
staphylococcus  is  given  in  doses  commencing  at  100  to  250 
millions,  and  rising  to  500  or  1,000  millions ;  the  streptococcus 
in  increasing  doses  of  2,  3,  5,  10,  20  millions,  and  more.  The 
treatment  may  extend  over  several  months. 

Vaccine  treatment  is  frequently  successful  in  reducing  and 
causing  the  disappearance  of  cystitis,  but  in  many  cases  bacilluria 
remains  and  resists  all  treatment,  and  at  a  later  date  relapses  of 
the  cystitis  occur. 

LITERATURE 

Brown,  Johns  Hopkins  Hosp.  Repts.,  1901,  p.  1. 
Faltin,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1902,  p.  176. 
Halle  et  Motz,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1902,  p.  17. 
Joubert,  VII^   Sess.  de  I'Assoc.  frang.  d'UroL,  Paris,  1903,  p.  7, 
Lichtenstein,  Wien.  Bin.  Woch.,  1904;   ibid.,  1907,  Nr.  40. 
Melchior,  Monats.  f.  d.  Krankh.  d.  Ham-  u.  Sex.-Apparat.,  1898,  p.  581. 
Motz  et  Denis,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1903,  p.  898. 
Motz  et  Montfort,  A7in.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1903,  p.  1211. 
Newman,  Lancet,  1912,  i.  490,  570. 
'         Raskai,  Monats.  f.  Urol.,  1905,  p.   1. 

Stoerk,  Zieglers  Beitr.  z.  path.  Anat.,  1911,  1.  361. 
Stoerk  und  Zuckerkandl,  Zeits.  f.  Urol.,  1907,  p.  3. 
Suter,  Zeits.  /.  Urol.,  1907,  p.  97. 
Zuckerkandl,  Monats.  f.   fjroL,  Bd.  vii. 


CHAPTER  XXXIII 
TUBERCULOUS  CYSTITIS 

Tuberculous  cystitis  is  said  to  be  primary  or  secondary,  accord- 
ing to  whether  it  is  the  original  focus  in  the  genito-urinary  organs, 
or  is  dependent  upon  a  tuberculous  focus  in  the  kidney  or  the 
male  genital  system. 

Primary  tuberculosis  in  the  strict  sense  that  the  vesical  tuber- 
culosis is  the  primary  focus  in  the  body  does  not  exist. 

Etiology. — Vesical  tuberculosis  occurs  in  youth  and  early 
adult  life,  and  is  more  common  in  men  than  in  women.  Cases 
of  senile  vesical  tuberculosis  are  occasionally  observed. 

Primary  tuberculosis  invades  the  mucous  membrane  of  the 
bladder  by  the  blood  stream.  At  the  present  time  there  is  con- 
siderable doubt  as  to  whether  this  form  of  tuberculosis  ever  occurs. 
The  evidence  for  it  is  clinical  and  cystoscopic.  The  clinician  finds 
that  symptoms  of  vesical  tuberculosis  are  present  without  symp- 
toms of  renal  or  genital  infection,  and  the  cystoscopist  sees  tuber- 
culosis of  the  bladder  mucous  membrane  while  the  orifices  of  the 
ureters  are  healthy.  Neither  of  these  observations  is  reliable,  for 
it  can  be  proved  by  catheterization  of  the  ureters  that  under  these 
conditions  tuberculosis  of  the  kidney  may  exist.  Since  I  have 
relied  upon  the  ureteral  catheter  in  every  case  for  a  decision  on 
this  point,  I  have  not  met  with  a  single  case  of  primary  tuberculosis 
of  the  bladder. 

In  cystitis  secondary  to  renal  tuberculosis  there  is  either  direct 
spread  by  continuity  along  the  ureter  to  the  bladder,  or  the  deposit 
of  tubercle  from  the  infected  urine.  In  cystitis  secondary  to 
genital  tuberculosis  the  tuberculous  process  either  passes  directly 
through  the  bladder  wall  from  the  seminal  vesicles  or  prostate,  or 
spreads  from  a  dilated  and  tuberculous  prostatic  urethra  into  the 
bladder.  In  cases  in  which  the  bladder  and  kidneys  are  tuber- 
culous, much  discussion  has  arisen  as  to  whether  the  tuberculous 
process  is  primary  in  the  kidney  and  the  infection  of  the  bladder 
a  descending  one,  or  the  tuberculosis  of  the  bladder  is  primary 
and  the  infection  of  the  kidney  ascending '  and  secondary. 

At  one  time  the  ascending  theory  was  universally  held,  and 

437 


438  THE   BLADDER  [chap. 

was  based  upon  (1)  the  early  appearance  of  vesical  symptoms  in 
urinary  tuberculosis,  (2)  some  post-mortem  records,  and  (3) 
experimental  work. 

Cystoscopy  has  proved  that  the  early  symptoms  of  cystitis 
in  urinary  tuberculosis  are,  in  the  majority  of  cases,  reflex ;  that 
the  bladder  is  healthy,  or  at  least  non-tuberculous ;  and  that  the 
kidney  may  be  totally  destroyed  by  tuberculosis  without  giving 
rise  to  renal  symptoms.  Post-mortem  records  which  are  quoted 
in  support  of  the  ascending  view  show  the  tuberculous  process 
surrounding  the  ureteric  orifice  of  the  affected  kidney,  and  might 
equally  be  quoted  in  proof  of  secondary  descending  infection  of 
the  bladder.  Apart  from  cases  of  genital  tuberculosis,  tubercu- 
losis of  the  bladder  is  almost  without  exception  accompanied  by 
tuberculosis  of  the  kidney ;  whereas  tuberculosis  of  the  kidney, 
or  kidney  and  ureter,  is  frequently  present  without  tuberculosis  of 
the  bladder.  The  experimental  production  of  ascending  tuber- 
culosis of  the  kidney  in  animals  by  Albarran,  Wildbolz,  and  others 
has  proved  that  by  injecting  tubercle  bacilh  into  the  bladder 
and  ligaturing  the  urethra,  or  into  the  ureter  and  ligaturing  the 
ureter,  a  tuberculous  infection  of  the  kidney  can  be  produced. 
In  all  these  experiments  the  element  of  obstruction,  temporary 
or  permanent,  is  superadded  to  the  introduction  of  the  tubercle 
bacillus,  a  condition  not  found  in  tuberculosis  in  the  human 
subject. 

Baumgarten  has  demonstrated  that  the  tuberculous  infection 
cannot  spread  against  the  stream  of  the  secretion  in  which  the 
bacilli  are  suspended.  Not  only  does  he  deny  the  possibility  of 
ascending  infection  of  the  kidney,  but  he  holds  that  tuberculosis 
of  the  prostatic  urethra  cannot  affect  the  epididymis  by  spreading 
back  along  the  vas  deferens. 

In  the  female  the  combination  of  urinary  tuberculosis  with 
genital  tuberculosis  is  very  rare,  and  the  infection  of  the  urinary 
from  the  genital  tract  does  not  occur. 

Pathology. — The  distribution  of  the  tuberculous  process  is 
frequently  significant  of  its  origin.  It  surrounds  one  ureter  in 
cases  in  which  the  infection  has  spread  along  the  ureter  from 
the  kidney.  When  the  process  has  commenced  in  the  seminal 
vesicle  it  is  found  immediately  behind  the  trigone  ;  when  a  tuber- 
culous collection  has  ruptured  through  the  bladder  wall  from 
the  prostate  a  crater -like  ulcer  is  foimd  on  one  side  of  the  trigone. 
In  tuberculosis  of  the  prostate  tubercles  may  be  found  in  the 
prostatic  urethra,  and  tuberculous  ulceration  extending  from  this 
part  of  the  urethra  into  the  bladder.  A  tuberculous  collection  of 
the  prostate  may  rupture  into  the  prostatic  urethra  and  spread 


xxxTTT]  TUBRRGULOUS    CYSTITIS  439 

thence  into  the  bladder,  the  outlet  of  the  bladder  and  the  prostatic 
urethra  being  sometimes  indistinguishable. 

The  tuberculous  process  commences  in  the  mucous  membrane 
as  greyish  tubercles  surrounded  by  inflammation.  (Plate  31, 
Fig.  4.)  These  become  yellow  from  caseation  and  break  down, 
forming  a  tiny  superficial  ulcer,  the  size  of  a  pin's  head,  with 
sharply  cut  edges,  and  sometimes  covered  with  blood  clot. 
(Several  of  these  fuse  and  form  larger  ulcers. 

Very  extensive  superficial  ulceration  may  be  present,  covering 
a  large  area  of  the  bladder  wall.  The  exposed  surface  is  pinkish- 
red  and  granular,  and  to  it  adhere  numerous  small  white  flakes. 
Deep  ulcers  may  also  be  found.  (Plate  31,  Fig.  5.)  They  are 
round,  oval,  or  serpiginous.  The  base  is  greyish-red  and  granular, 
the  edge  deeply  undermined,  and  often  with  a  thin,  frayed  margin 
of  necrosing  mucous  membrane.  The  edge  is  not  heaped  up 
above  the  mucous  membrane,  and,  where  the  condition  is  chronic, 
yellow  tubercles  are  dotted  around  with  little  surrounding  inflam- 
mation. Evidence  of  .healing  may  be  found  at  one  part  of  the 
ulcer,  and  of  spreading  at  another.  In  chronic  tuberculous  cystitis 
where  there  is  no  infection  by  other  bacteria  the  lesions  are  discrete, 
the  intervening  mucous  membrane  being  healthy.  If  infection 
with  other  bacteria  is  superadded  these  characteristics  are  lost, 
but  the  serpiginous  outline  is  retained.  Irregular  masses  of  granu- 
lation tissue  may  be  found.  Widespread  infiltration  of  the  sub- 
mucous tissue  and  of  the  muscular  coat  takes  place.  In  long- 
standing tuberculosis  the  bladder  becomes  contracted  and  fibrous. 
The  perivesical  fat  is  thickened  and  fibrous,  and  the  bladder 
becomes  adherent  to  the  rectum  and  intestine  and,  in  the  female,  to 
the  genital  organs.  The  pelvic  lymphatic  glands  are  tuberculous, 
but  the  formation  of  a  tuberculous  abscess  is  very  rare.  In  a 
few  cases  the  bladder  cavity  remains  large  and  the  wall  is  trans- 
formed into  a  thin  fibrous  layer,  the  contractile  power  of  which 
is  lost. 

Together  with  these  changes  there  is  tuberculosis  of  the  kidney 
on  one  or  both  sides,  or  tuberculosis  of  the  seminal  vesicles  or 
prostate.  Genital  tuberculosis  in  the  female  is  rarely  found  com- 
bined with  vesical  tuberculosis. 

Symptoms. — The  symptoms  are  those  of  spontaneous  cystitis 
in  a  young  man  or  woman.  The  onset  is  insidious,  and  the  pro- 
gress gradual  but  persistent.  Variations  in  intensity  of  the  symp- 
toms frequently  follow  dietetic  indiscretions  and  chmatic  changes. 
Frequent  micturition  is  the  earliest  symptom.  At  first  this  is 
diurnal  and  moderate,  the  call  coming  every  two  or  three  hours, 
but  it  is  progressive  and  becomes  nocturnal  and  sleep  is  disturbed. 


440  THE  BLADDER  [chap. 

Small  quantities  of  urine  are  passed  every  quarter-  or  half-hour 
during  the  day,  and  slightly  less  frequently  at  night.  Micturition 
is  urgent,  and  if  the  patient  sleeps  heavily  the  urine  is  passed  in- 
voluntarily. Pain  and  intense  desire  are  felt  at  the  neck  of  the 
bladder  when  the  patient  attempts  to  hold  water  too  long.  There 
is  scalding  along  the  urethra  during  micturition,  and  cramp-like 
pain  in  the  bladder  and  pain  at  the  end  of  the  penis,  or  at  the 
external  meatus  in  the  female. 

Hsematuria  is  a  frequent  symptom,  a  few  drops  of  bright  blood 
passing  at  the  end  of  micturition.  In  some  cases  there  are 
occasional  attacks  of  more  severe  heematuria  at  long  intervals. 

The  urine  is  pale,  faintly  acid,  of  low  specific  gravity,  and 
contains  numerous  fine  dots  and  shreds,  and  a  small  quantity  of 
pus  well  mixed,  which  gives  it  an  opalescent  appearance.  Poly- 
uria is  present,  and  may  be  ascribed  to  the  reflex  effect  of  the 
frequent  contractions  of  the  bladder,  but  is  probably  the  result 
of  tuberculous  changes  in  the  kidneys.  The  quantity  of  pus  is 
small,  but  it  is  constant.  The  symptoms  are  unaffected  by  move- 
ment, but  are  influenced  by  dietetic  indiscretions  and  cold  damp 
weather. 

Complications. — Severe  hsematuria  is  rare.  Retention  of  urine 
is  an  unusual  complication.  It  may  occur  when  there  is  tuber- 
culosis of  the  prostate,  and  I  have  met  with  it  twice  as  a  post- 
operative complication  lasting  several  days  after  nephrectomy  for 
renal  tuberculosis  in  women.  The  most  serious  complication  is 
septic  infection.  The  bacillus  coli,  staphylococcus,  and  strepto- 
coccus are  the  bacteria  most  frequently  present,  and  are  almost 
invariably  introduced  by  the  passage  of  instruments  or  by  wash- 
ing the  bladder.  With  the  advent  of  a  mixed  infection  the  symp- 
toms increase  in  intensity.  The  cystitis,  which  may  have  been 
localized  to  one  part  of  the  bladder,  becomes  general,  and  septic 
pyelonephritis  may  be  superadded  to  the  tuberculous  process  in 
the  kidney. 

Course  and  prognosis. — The  course  of  tuberculous  cystitis 
when  instrumental  interference  is  withheld  is  slowly  progressive, 
with  periods  of  improvement  and  periods  of  relapse,  dependent 
partly  upon  changes  of  diet  and  climate.  There  may  be  a  period 
of  acute  cystitis  at  the  commencement,  which  subsides,  a  slight 
subacute  cystitis  persisting.  More  frequently,  however,  the  onset 
is  insidious  and  the  progress  very  gradual.  After  some  years 
the  nocturnal  calls  to  micturate  become  very  distressing,  and 
the  patient  is  worn  out  with  loss  of  sleep.  If  septic  complica- 
tions are  avoided,  death  takes  place  after  some  years  from  renal 
failure  due  to  bilateral  renal  tuberculosis.     More  often  there  are 


xxxm]  TUBERCULOUS  CYSTITIS:   DIAGNOSIS    441 

septic  coinplicatioiis,  occasionally  with  secoiidaiy  stone  foniiatioii 
and  subacute  or  chronic  septic  pyehMiephritis.  Where  vesical 
tuberculosis  is  secondary  to  renal  tuberculosis  which  is  unilateral, 
and  nephrectomy  is  perfor)ned,  the  tu))erculous  disease  of  the 
bladder  may  entirely  disappear  without  further  treatment.  The 
same  may  occur  when  the  lumen  of  the  ureter  becomes  perma- 
nently obliterated  without  operation  {closed  renal  tuberculosis). 
When  the  tuberculous  process  is  secondary  to  disease  of  the  pros- 
tate or  seminal  vesicle  the  prognosis  is  less  favoura?jle,  owing  to 
the  difliculty  of  eradicating  the  primary  focus. 

Diagnosis. — The  spontaneous  development  of  slight  persistent 
and  progressive  vesical  irritation  in  youth  or  early  adult  life, 
when  venereal  disease  can  be  excluded,  should  raise  the  suspicion 
of  tuberculosis  of  the  bladder. 

On  cystoscopy  the  presence  or  absence  of  cystitis  is  definitely 
ascertained.  If  it  is  present,  the  following  questions  must  be 
answered  : — 

1.  Is  the  cystitis  tuberculous  ? — (a)  Examination  of  the 
urine.  The  urine  is  pale,  faintly  acid,  opalescent,  with  a  small 
quantity  of  suspended  pus,  and  contains  small  white  dots  and 
shreds.  The  discovery  .of  the  tubercle  bacillus  in  the  urine  is 
conclusive.  The  bacilli  are  more  easily  found  when  slight  haemor- 
rhage is  in  progress.  Failure  to  discover  the  tubercle  bacillus  on 
one  occasion  should  not  be  accepted  as  final,  and  repeated  exam- 
inations may  be  necessary.  Inoculation  of  animals  with  the 
suspected  urine  should,  if  necessary,  be  carried  out. 

(b)  Tuberculous  disease  may  be  found  in  the  epididymis, 
seminal  vesicles,  or  prostate,  or  in  the  lungs  or  elsewhere  in  the 
body. 

(c)  The  cystoscope  shows  characteristic  appearances.  There 
are  greyish-yellow  opaque  tubercles  distinguished  by  being  small, 
discrete,  opaque,  and  having  the  appearance  of  pushing  through 
the  inflamed  mucous  membrane,  which  distinguishes  them  from 
the  small  cysts  of  cystic  cystitis — semitransparent,  often  closely 
grouped,  and  set  upon  the  surface  of  the  mucous  membrane, 
which  is  seldom  much  inflamed. 

Chronic  deep  ulceration  with  undermined  edges,  heahng  at 
one  part  and  spreading  at  another,  is  characteristic  of  tubercu- 
losis. There  may  be  general  acute  cystitis,  or  extensive  super- 
ficial ulceration,  or  heaping-up  of  granulation  tissue,  none  of  which 
is  characteristic  of  tuberculosis. 

2.  Is  the  tuberculous  cystitis  secondary  to  renal  or  to 
genital  tuberculosis  ? — Basal  grouping  of  the  tuberculous  cyst- 
itis behind  or  on  one  side  of  the  trigone,  together  with  nodules 


442 


THE  BLADDER 


[chap. 


in  the  seminal  vesicles  or  prostate,  shows  that  the  primary  focus 
is  in  these  organs. 

The  presence  of  tuberculosis  of  the  kidney  is  ascertained  by 


Fig.  120. — Specimen  of  bladder,  ureters,  and  prostate  in 
case  of  urinary  tuberculosis. 

Universal  tuberculous  ulceration  of  bladder,  the  wall  of  which  is  much  thickened  ;  right  ureter 

normal,  left  ureteric  orifice  dragged  upwards  and  outwards  and  ureter  thickened  and  dilated. 

There  was  advanced  tuberculosis  of  the  left  kidney, 

examining  the  orifice  of  the  ureter.     Changes  at  the  orifice  and 
grouping  of  tuberculous  inflammation  round  it  show  disease  of 


xxxm]  TUBERCULOUS  CYSTITIS:  TREATMENT  113 

Mh'.  corri'spoiidiiiif  kidney.  (Ki^j.  l-<».)  The  Absence  of  cliaiiges  ut 
(he  secoiul  ureteral  oiifiee  doe.s  not  exclude  tuberculous  disease 
of  that  kidney,  and  when  both  ureteric  orifices  are  healthy  renal 
tuberculosis  may  still  be  present.  The  only  i-eliable  test  is  the 
passage  of  the  ureteric  catheter  and  examination  of  the  urine 
withdrawn  by  it  for  pus  and  the  tubercle  bacillus. 

Treatment. — When  tuberculous  cystitis  is  secondary  to  renal 
tuberculosis,  the  kidney,  if  one  only  is  affected,  should  be  removed, 
and  in  the  majority  of  cases  the  cystitis  diminishes  and  completely 
disappears.  When  bilateral  renal  tuberculosis  is  present,  when 
the  cystitis  is  secondary  to  tubercle  of  the  prostate  or  seminal 
vesicle,  when  an  active  focus  of  tubercle  exists  elsewhere  in  the 
body,  when  no  renal  or  genital  tuberculosis  can  be  demonstrated, 
or  when  the  cystitis  does  not  disappear  after  nephrectomy,  other 
treatment  is  necessary. 

General  treatment. — Residence  in  a  warm,  dry  climate,  such 
as  Egypt  and  Algiers,  has  a  very  beneficial  influence.  Arcachon, 
Biarritz,  and  the  French  or  Italian  Riviera  are  also  suitable 
resorts  for  these  tuberculous  patients.  The  food  should  be  plain 
and  nourishing.  Articles  known  to  irritate  the  urinary  tract, 
such  as  curries  and  highly  spiced  foods,  and  all  alcoholic  drinks, 
should  be  avoided.  Plenty  of  milk  and  eggs  and  cod-liver  oil 
in  suitable  quantity  should  be  taken. 

If  the  infection  is  mixed,  urinary  antiseptics  should  be  used, 
but  in  pure  tubercle  they  have  no  effect. 

Guaiacol,  5  minims  in  capsule,  thrice  daily,  has  been  recom- 
mended, and  cacodylate  of  soda,  i-1  gr.  hypodermically,  or  guaiaco- 
cacodylate,  J-2  gr.  hypodermically,  and  disodium  methylarsenate, 
r-3  gr.  hypodermically,  have  also  been  used.  Sandalwood  oil, 
10  minims  in  capsule,  should  be  given  for  its  soothing  effect  on 
the  bladder,  and  belladonna  and  hyoscyamus  to  reduce  the  spasm 
of  the  bladder. 

Tuberculin  should  be  given  in  all  cases,  and  very  striking 
results  are  frequently  obtained.  The  pain,  frequency,  and  irrita- 
bility diminish,  the  blood  disappears  from  the  urine,  and  the 
patient  increases  in  body  weight.  When  the  cystitis  is  secondary 
to  renal  tuberculosis  marked  improvement  is  observed  in  early 
cases,  sometimes  "with  the  disappearance  of  pus  and  tubercle 
bacilli  for  varying  periods.  The  tuberculous  disease  of  the  bladder 
may  completely  disappear,  and  the  ureter  of  the  diseased  kidney 
is  found  to  be  occluded.  Relapses,  however,  occur,  and  observa- 
tions extending  over  a  few  months  are  worthless  in  regard  to  the 
permanence  of  the  cure.  In  genito-urinary  tuberculosis  the  re- 
sults are  less  favourable,  but  amelioration  of  the  symptoms  may 


444  THE   BLADDER  [chap,  xxxiii 

be  anticipated,  and '  occasionally  the  genital  tuberculosis  heals 
under  the  treatment.  The  method  of  administration  has  been 
described  elsewhere  (p.  238). 

Local  treatment. — I  am  opposed  to  the  local  treatment  by 
means  of  bladder-washing  and  instillations.  Temporary  improve- 
ment is  observed  in  many  cases,  but  septic  complications  almost 
invariably  supervene  and  the  patient  is  placed  in  a  much  worse 
condition.  As,  however,  this  view  is  not  universally  held,  the 
following  details  of  these  methods  are  given:  The  bladder  has 
been  washed  with  boric  acid  and  other  solutions  containing  anti- 
pyrin  or  opium  to  soothe  the  pain.  Instillations  of  |-1  drachm 
of  various  drugs  have  also  been  given  with  a  small  syringe  under 
strict  aseptic  precautions.  Corrosive  sublimate  is  used  in  strengths 
of  1  in  10,000  up  to  1  in  5,000,  the  injections  being  repeated  every 
two  or  three  days  and  continued  for  a  long  time.  With  iodoform 
in  liquid  paraffin,  5  per  cent.,  may  be  combined  guaiacol,  5  per 
cent.,  which  has  the  advantage  of  being  analgesic.  Gomenol,  10 
or  20  per  cent.,  in  oil,  has  been  instilled  daily,  or  given  in  alter- 
nation with  the  corrosive  sublimate  instillations.  Picric  acid,  J-l 
per  cent,,  and  carbolic  acid,  5  per  cent.,  have  also  been  used. 

Treatment  by  direct  appHcations  may  be  made  in  either  sex 
through  Luys'  direct  cystoscopy  In  this  way  ulcers  may  be 
scraped  or  cauterized  with  the  electric  cautery,  with  nitrate  of 
silver,  or  lactic  acid.  Cystotomy  may  be  performed  either  for 
drainage  alone  or  for  drainage  after  treatment  of  the  tuberculous 
ulcers. 

In  the  extremely  rare  cases  where  a  single  ulcer  is  present  it 
is  excised.  In  other  cases  the  ulcers  are  curetted,  cauterized, 
or  treated  with  silver  nitrate,  chloride  of  zinc,  or  other  caustics, 
and  the  bladder  is  drained.  Suprapubic  cystotomy  is  prefer- 
able to  perineal  cystotomy,  for  it  permits  of  local  applications. 

Temporary  relief  may  be  obtained  by  these  methods,  but  in 
a  few  months  the  condition  relapses,  and  sepsis  is  invariably  super- 
added, so  that  the  condition  of  the  patient  is  worse  than  before 
the  operation. 

LITERATURE 

Casper,  Deuts  med.  WocJi.,  1900,  p.  661. 

Fenwick,  Trans.  Med.  Soc,  1905,  xxvii.  242. 

Halle  et  Motz,  Ann.  d.  Mai.  d.  Org.  Gin.-  JJrin.,  1904,  p.  161. 

Karo,  Med.  Bee,  Oct.  2,  1909. 

de  Keersmackers,  CentralU.  f.  d.  Kranhh.  d.  Earn-  u.  Sex.-Org.,  1906,  p.  413. 

Pardoe,  Lancet,  1905,  ii.  1766. 

Rovsing,  Arch.  f.  Bin.  CMr.,  1907,  p.  1. 

Suter,  CentralU.  /.  d.  Kranhh.  d.  Ham-  u.  Sex.-Org. ,  1901,  p.  657. 

Walker,  Thomson,  Pract.,  May,  1908. 


CHAPTER  XXXIV 
OTHER  INFECTIONS  OF  THE  BLADDER 

BILHAEZIOSIS 

Etiology. — Bilharziosis  is  caused  by  a  trematode  worm  named 
the  Bilharzia  hcematohia  or  Schistosomum  hcematohium. 

The  disease  is  endemic  in  certain  countries.  In  Africa,  in- 
cluding Egypt,  it  is  most  prevalent,  especially  in  Lower  Egypt, 
where  it  is  found  in  about  one-third  of  the  autopsies.  Ferguson 
states  that  about  one-half  of  the  agricultural  population  of  Egypt 
are  shedding  blood  and  bilharzia  ova  in  their  urine  and  faeces 
daily — a  very  serious  drain  on  themselves,  and  a  constant  menace 
to  their  neighbours  as  a  source  of  infection  and  re-infection.  He 
found  the  disease  present  post  mortem  in  40  per  cent,  of  600  male 
subjects  from  5  years  of  age  upwards.  Madden  found  that  10  per 
cent,  of  11,698  patients  had  bilharziosis.  It  occurs  also  in  Tunis, 
Algiers,  on  the  west  coast  of  Africa  (Nigeria,  etc.),  and  on  the  east 
coast  (Abyssinia,  Zanzibar,  Madagascar).  In  South  Africa  it  is 
common  in  Delagoa  Bay,  Natal,  the  Eastern  Province  of  Cape 
Colony,  and  the  Transvaal.  The  disease  has  been  met  with  in 
Japan  and  China.  In  England  a  large  number  of  cases  were 
imported  after  the  South  African  War.  Major  Smith,  R.A.M.C., 
reports :  "In  ordinary  times  soldiers  serving  in  South  Africa 
were  little  subject  to  the  disease,  and  it  seems  to  have  been  of 
very  minor  importance  as  a  cause  of  ill-health  in  former  cam- 
paigns in  that  country.  The  Army  Medical  Department  Reports 
for  the  period  1890  to  1898,  when  the  garrison  had  an  average 
numerical  strength  of  4,164,  made  no  mention  of  bilharzia,  while 
the  reports  dealing  with  the  sick  statistics  of  the  Zulu  and  first 
Boer  Wars  contain  no  reference  to  it."  The  actual  number 
admitted  to  hospital  during  the  South  African  campaign  (1899- 
1902)  was  187,  but  the  slighter  cases  were  probably  unnoticed 
or  disregarded.  All  the  cases  that  came  under  observation 
were  mild  (Simpson). 

Mode  of  infection. — Infection  takes  place  after  bathing  or 
prolonged  immersion  in  infected  rivers  or  pools,   and,  it  is  also 

445 


446  THE   BLADDER  [chap. 

stated,  from  the  constant  soaking  of  the  bare  feet  in  the  rice 
fields.  The  incubation  period  is  about  three  to  six  months.  Males 
are  much  more  frequently  affected  than  females  in  the  proportion 
of  93-2  males  to  6-8  females  (Madden).  The  disease  is  very  common 
in  boys ;  Kautsky  found  that  79  per  cent,  of  boys  in  a  school 
near  Cairo  had  bilharziosis.  Agricultural  labourers  and  dwellers 
in  the  country  are  more  frequently  affected  than  town  dwellers. 
Looss  found  that  30-5  per  cent,  of  boys  in  a  school  in  Cairo,  and 
80  per  cent,  in  a  school  in  the  outskirts  of  the  same  town,  had 
hsematuria.     The  path  by  which  invasion  takes  place  is  disputed. 

(a)  The  stomach. — ^The  embryo  is  supposed  to  be  swallowed 
in  the  water  during  bathing  or  in  drinking  water.  Against  this 
theory  is  the  fact  that  the  embryo  is  killed  by  a  much  weaker 
solution  of  hydrochloric  acid  than  is  present  in  the  normal  stomach. 

(b)  Through  the  urethra  or  anus. — Allen  holds  that  the  parasite 
enters  the  urethra  during  prolonged  immersion  in  infected  water, 
and  that  it  is  more  likely  to  do  so  if  there  is  a  long  prepuce  and 
care  is  not  taken  to  dry  the  parts  thoroughly  after  bathing.  Cir- 
cumcision he  regards  as  a  valuable  preventive  measure. 

(c)  Penetration  of  the  skin. — This  is  held  by  most  authorities 
to  be  the  probable  path  of  invasion.  It  is  chiefly  male  earth- 
workers  in  country  districts  and  their  children  who  are  affected. 

Life-history  of  the  trematode. — The  male  worm  is  1  cm. 
long,  flat,  and  with  the  lateral  margins  incurved  to  form  a  canal, 
and  the  female  2  cm.  long  ;  they  are  thread-like,  and  possess 
two  suckers.  The  sexes  are  separate  in  the  early  stage,  and  at 
this  time  they  occupy  the  portal  vein.  With  sexual  maturity  they 
unite  and  find  their  way  against  the  blood-stream  to  the  veins 
of  the  submucous  tissue  of  the  bladder  and  rectum.  (Fig.  121.) 
The  eggs  deposited  by  the  female  penetrate  the  mucous  mem- 
brane, and  are  shed  and  appear  in  the  urine  and  faeces.  The  ova 
are  elliptical,  and  are  contained  in  a  thin  yellow  envelope  which 
has  a  spine  at  the  posterior  end.  Larger  ova  with  a  lateral  spine 
are  also  found,  most  frequently  in  the  liver  or  the  rectum,  and  are 
probably  deformed.  If  the  ovum  is  placed  in  fresh  water  a  ciliated 
embryo  (Miracidium)  escapes  from  the  envelope  and  swims  vigor- 
ously, and  can  be  kept  alive  for  twenty-four  to  forty-eight  hours. 
The  length  of  life  of  the  worms  is  unknown.  When  they  die  the 
supply  of  ova  ceases  and  the  symptoms  subside  and  disappear. 
The  severe  cases  met  with  in  Egypt  are  probably  the  result  of 
often- repeated  infection. 

Pathology. — The  disease  affects  the  ureter  (Fig.  121),  bladder 
(Figs.  122,  123),  urethra,  and  rectum,  and  rarely  other  parts  of  the 
body.     Only  urinary  bilharziosis  will  be  considered  here. 


Fig.   1, — Bilharzial  nodules  in  bladder.     (P.  447. J 
Fi^.  2. — Bilharzial  granulations  in  bladder.     (P.  447.) 
Fig.  3.— Villous  papilloma  of  bladder,     (P.  461.) 

Plate  32. 


XXX IV] 


BILHARZIOSIS :    PATHOLOGY 


447 


The  mucous  membrane  becomes  red  and  injected,  and  then 
inflamed  and  (Edematous  in  patches.  In  these  areas  small  yellow- 
ish-grey nodules  the  size  of  a  millet-seed  appear,  and  these  rupture 
and  leave  ulcers,  sometimes  of  considerable  extent,  which  become 
covered  with  gramilation  tissue.  (Plate  32,  Fig.  1.)  The  mucous 
membrane  has  a  brownish,  sandy  appearance  in  patches.  Irregular 
excrescences  of  granulation  tissue  spread  from  the  surface,  forming 


o^S''  ,Vv.' '■•.•.;•;    „    •,■■.■■.■■.■  •■.■<'7'^ ■■■<>-'■  ■'.-•■•"■.••    '.•'•:■••■•.•.■•■■•" 


Fig.  121.^ — Wall  of  ureter  in  case  of  bilharziosis,  showing 
male  and  female  worms  in  vein. 

The  worms  are  cut  transversely.     The  outer  body  with  radiating  structure  is  the  male  worm, 

while  the  female  lies  enfolded  in  the  genital  groove.     A  fold  of  the  female  worm  has  been  cut 

so  that  it  appears  as  two  bodies.     {Section  Jtrcsentcd  by  P>-o/cssor  A.  R.  Ferguson,  Cairo.) 

papilloma-like  masses,  or  in  ridges  like  the  comb  of  a  cock.  These 
patches  are  adherent  to  the  submucous  tissue.  (Plate  32,  Fig.  2.)  ' 
Microscopically  there  is  proliferation  of  the  epithelium,  which 
may  grow  downwards  in  glandular  and  cystic  forms.  (Fig.  123.) 
The  submucous  tissue  is  infiltrated  and  adherent.  Ova  are  found 
in  the  mucous  membrane,  especially  in  the  epithelial  layer.  They 
are  perivascular  in  their  grouping,  suggesting  a  position  in  the 
lymphatics.     They  increase  in  numbers  with  the  duration  of  the 


448 


THE  BLADDER 


[chap. 


infection,  few  being  seen  in  children  and  large  numbers  in  adults. 
Stained  with  hsematoxylin,  the  living  ova  are  blue,  and  dead  ova 
violet.  (Fig.  122.)  Old  dead  ova  may  become  calcified.  The 
granular  masses  consist  of  thickened  inflamed  mucous  mem- 
brane with  granulation  tissue  and  numerous  ova.  True  papillo- 
matous tumours  may  develop,  and  malignant  growths  (carcinoma 
and  sarcoma)  are  very  frequently  observed.  Ferguson  has  de- 
scribed 40  cases  of  malignant  growth  associated  with  bilharziosis 


mi 


^^FOf^a 


Fig.  122. — Section  of  bilharzial  nodule  in  bladder. 

There  is  a  heaped-up  mass  of  tubes  of  epithelium,  in  which  are  embedded  numerous  bilharzial  ova. 

{Sectioti presented  by  P7-ofessor  A.  R.  Ferguson.,  Cairo^ 

of  the  bladder.  The  posterior  wall  was  most  frequently  affected, 
but  in  many  cases  the  whole  bladder  was  a  rigid  spherical 
mass.  In  34  cases  the  growth  was  carcinomatous — usually  squa- 
mous epitheUoma ;  in  6  it  was  sarcomatous.  Lymph-glands 
were  frequently  affected. 

In  severe  cases  sepsis  is  almost  invariably  superadded,  the 
urine  becomes  alkaline,  there  is  widespread  ulceration  and  sloughing 
of  the  epithelium  and  granulation  tissue. 

The  interior  of  the  bladder  becomes  encrusted  with  phosphatic 
material,    from   which   portions   may   be   detached,    forming  the 


xxxiv] 


BILHARZIOSIS  :    PATHOLOGY 


449 


nucleus  of  larger  calculi.  The  bladder  is  contracted,  and  ascend- 
ing pyelonephritis  combined  with  dilatation  of  the  ureters  and 
the  pelvis  of  the  kidneys  is  common,  and  leads  to  a  fatal  termina- 
tion. In  a  number  of  cases  the  urethra  also  becomes  involved ; 
ulceration  of  the  mucous  membrane  follows,  and  a  deep  crater 
coated  wdth  phosphates  is  formed.  Aroimd  this  an  abscess 
usually  develops,  which  ruptures  in  the  perineum,  and  sinuses 
form.  Madden,  who  has  described  this  condition,  points  out  that 
the  bulbous  urethra  is  the  Dart  affected,  and  that  the  sinuses  start 


Fig.   123. — Section  of  bladder  wall  in  bilharziosis. 

Down-growths  of  epithelium  into  submucous  layer. 

(Section  fii-escntcd  by  Proft-ssor  A.  R.  FcrgKson,  Cah-o.) 

from  the  urethra  either  laterally  or  even  from  the  roof  and  track 
round  between  the  corpus  cavernosum  and  corpus  spongiosum, 
opening  to  one  side  of  the  middle  of  the  perineum  and  sometimes 
tracking  round  the  anus  on  to  the  buttocks,  scrotum,  or  pubes. 
A  characteristic  false  elephantiasis  of  the  scrotum  and  perineum 
may  be  produced  by  multiple  fistulse.  The  penile  urethra  may 
also  be  afiected,  and  when  the  lesions  are  confined  to  the  terminal 
one  or  two  inches  there  is  sohd  oedema  of  the  glans  and  prepuce, 
sometimes  accompanied  by  purulent  urethral  discharge.  The 
whole  penis  may  be  involved,  and  there  may  be  numerous  fistulse 
communicatino;  with  the  urethra.  Ulceration  of  the  sjlans  mav 
lead  to  epithelioma.     There  may  be  nodules  in  the  subcutaneous 


450  THE   BLADDER  [chap. 

and  erectile  tissues  of  the  peiiis.  The  latter  lead  to  extensive 
infiltration  of  the  erectile  tissue  and  great  distortion  of  the  organ 
and  the  urethra.  The  prostate  and  seminal  vesicles  are  less  fre- 
quently affected. 

Symptoms. — Bilharziosis  may  exist  without  giving  rise  to 
symptoms.  Milton  found  that  of  35  cases  in  which  bilharzia  ova 
Avere  found  in  the  urine,  in  only  2  were  symptoms  of  bilharziosis 
complained  of.  In  bilharzial  cystitis  the  chief  symptom  is  heema- 
turia.  This  appears  spontaneously,  and  is  persistent,  although 
there  may  be  intervals  of  clear  urine  from  time  to  time.  The 
hsematuria  is  terminal,  a  few  drops  of  bright  blood  appearing  at 
the  end  of  micturition.  It  is  unaffected  by  movement.  Rarely 
more  severe  haemorrhage  occurs.  The  hsematuria  may  be  un- 
accompanied by  other  symptoms.  The  urine  contains  shreds  of 
various  shapes,  and  frequently  there  are  shreds  with  a  small 
terminal  blood  clot  in  which  an  ovum  can  be  found.  The  ova  are 
readily  found  on  microscopical  examination  of  the  urine.  Fre- 
quent micturition  and  slight  pain  at  the  end  of  the  penis  are  early 
symptoms  in  most  cases.  The  irritability  gradually  increases  and 
becomes  distressing  day  and  night. 

On  cystoscopy  small  yellow  bodies  about  the  size  of  a  canary- 
seed  are  found  projecting  from  the  mucous  membrane.  They  are 
usually  grouped  together  in  colonies,  and  a  colony  may  have  little 
or  no  surrounding  inflammation.  These  bodies  may  closely  re- 
semble tubercles  in  tuberculous  cystitis,  but  are  larger,  more 
prominent,  more  numerous,  and  more  distinctly  grouped.  The 
formation  of  ridges  of  infiltrated  mucous  membrane  on  which  are 
excrescences  of  granulation  tissue,  often  with  the  bilharzial  bodies 
dotted  around,  is  very  characteristic  of  the  disease.  Larger  areas 
may  be  raised,  and  granular  and  papillomatous  new  growths  may 
develop.  As  the  disease  advances  the  bladder  becomes  intensely 
irritable  and  cystoscopy  becomes  more  and  more  difficult. 

Complications. — In  the  later  stages  complications  occur. 
Sepsis  is  the  most  constant  of  these,  and  leads  to  an  intensely 
painful  form  of  cystitis  with  alkaUne  urine  and  phosphatic  en- 
crustation. Madden  describes  a  peculiar  grey-green  urine  charac- 
teristic of  the  advanced  stages  of  the  disease. 

Stone  is  a  frequent  complication.  Of  65  cases,  Goebel  found 
stone  in  34,  and  probable  stone  in  10  others.  When  the  urine  is 
still  acid  the  stones  may  be  composed  of  uric  acid  and  oxalate  of 
lime,  sometimes  with  alternating  layers  of  phosphates.  They 
have  as  a  nucleus  bilharzia  ova  or  portions  of  papillomas.  When 
the  urine  has  become  alkaline  they  are  invariably  phosphatic, 
and  may  originate  in  detached  portions  of  the  phosphatic  encrust- 


XXXIV]  BILHARZIOSIS :    TREATMENT  451 

ations  of  the  bilhaizial  ulcers.  Papillomatous  tumours  develop 
late  and  may  fill  the  whole  of  the  bladder.  Fistulae  appear  in 
the  perineum  and  suprapubically,  and  track  in  various  direc- 
tions. Malignant  growth  in  the  papillomatous  tumours  is  not 
uncommon  (p.  448). 

Prognosis. — The  type  of  bilharzial  disease  met  with  in  South 
Africa  and  imported  into  this  country  is  benign  compared 
with  the  bilharziosis  of  Egypt.  Colonel  Simpson,  R.A.M.C, 
states,  in  reference  to  the  cases  which  occurred  in  the  South 
African  campaign,  that  "  secondary  changes  involving  the  bladder 
and  other  parts  of  the  urinary  tract  have  not  come  under 
observation." 

The  virulence  and  malignancy  of  the  Egyptian  form  appears  to 
some  extent  to  depend  upon  the  prevalence  of  the  disease  and 
the  habits  of  the  agricultural  population,  which  give  opportunity 
for  repeated  re-infection.  In  ordinary  cases,  if  the  patient  leaves 
the  bilharzial  country  the  symptoms  disappear  in  about  four 
years.  I  have  re-examined  the  bladder  in  a  case  of  vesical  bil- 
harziosis after  an  interval  of  four  and  a  half  years,  and  found 
the  mucous  membrane  quite  healthy. 

The  mortahty  of  Egyptian  bilharziosis  or  its  immediate  com- 
plications is  just  over  10  per  cent.  (Madden). 

Treatment. — The  treatment  is  prophylactic  and  symptom- 
atic. No  method  of  destroying  the  schistosomum  is  known.  Pre- 
ventive measures  consist  in  forbidding  bathing  in  infected  rivers 
or  pools,  in  thorough  drying  where  a  risk  of  infection  has  been 
taken,  in  circumcision  of  boys,  and  in  boiling  drinking-water. 
Removal  of  the  patient  from  the  bilharzial  country  is  usually 
followed  by  recovery. 

In  the  early  stages  Madden  recommends  15  minims  of  the 
liquid  extract  of  male  fern  thrice  daily.  The  treatment  of  the 
cystitis  is  similar  to  that  already  described.  Urotropine,  methy- 
lene blue,  and  other  urinary  antiseptics  are  usually  administered. 
Washing  the  bladder  with  weak  solutions  of  silver  nitrate,  1  in 
10,000,  or  quinine,  4  per  cent.,  or  other  antiseptics,  or  instillation 
of  stronger  solutions,  may  be  carried  out,  especially  where  cystitis 
is  present.  Treatment  of  the  bladder  is,  however,  unsatisfactory, 
for  the  ova  in  the  mucous  membrane  are  constantly  being  renewed. 
When  stone  complicates  the  disease  litholapaxy  is  to  be  preferred 
to  cystotomy,  and  when  in  advanced  disease  bladder  drainage 
is  necessary  the  suprapubic  route  is  more  suitable  than  the 
perineal. 

Day  and  Richards  have  tried  salvarsan  in  the  treatment  of 
bilharziosis.  and  found  that  it  was  worthless. 


452  THE   BLADDER  [chap. 

LITERATURE 

Allen,  Lancet,  May  8,  1909,   and  Aug.  6,  1910. 

Day  and  Richards,  Lancet,  1912,  i.  1126. 

Elgood,  Brit.  Med.  Joiirn.,  Oct.  31,  1908. 

Ferguson,  Journ.  of  Path,  mid  Bad.,  1911,  p.  76. 

Goebel,  Deuts.  Zeits.  /.  Chir.,  1906,  p.  288. 

Kautsky,  Wien.  klin.  Bunds.,  No.  36. 

Looss,  Menses   Handbuch  der   TropenkranJcheiten. 

Madden,  Bilharziosis,  1907  ;    Lancet,  Oct.  23,  1909  ;    Journ.  of  Trop.  Med., 

Dec.  1,  1909  ;    Brit.  Med.  Journ.,  Oct.  1,  1910. 
Simpson,  Journ.  of  R.  A.M.  C,  1910,  p.  653. 
Wilson,  St.  Bart.'s  Hosp.  Bepts.,  xlv. 

SYPHILIS  OF   THE  BLADDEE 

Scattered  through  the  literature  there  are  descriptions  of 
syphilitic  affections  of  the  bladder.  In  the  majority  of  cases 
proof  of  the  syphilitic  nature  of  the  affections  has  been  confined 
to  the  history  of  a  syphilitic  infection  and  the  effect  of  treatment ; 
cystoscopic  and  bacteriological  examinations  have  been  wanting. 
Recently,  however,  the  writings  of  Frank,  von  Englemann,  Pere- 
schiwkin,  and  especially  an  exhaustive  article  by  Asch,  have 
placed  the  subject  on  firmer  ground. 

In  secondary  syphilis  symptoms  of  an  acute  or  chronic  cystitis 
develop,  frequent  micturition  and  the  presence  of  pus  being  most 
prominent.  On  cystoscopic  examination  there  is  congestion  and 
swelling  of  the  mucous  membrane,  and  multiple  small  superficial 
ulcers  with  indurated  edges  may  be  present.  Multiple  (twelve) 
superficial  round  or  oval  ulcers  with  undermined  edges  and 
whitish  base,  resembling  syphilitic  plaques,  have  also  been 
•described. 

In  tertiary  syphilis  there  may  be  gummata  or  ulcers,  or  both 
may  be  combined.  The  gummata  may  form  papillomas  which 
are  indistinguishable  from  other  forms  of  papilloma,  except  that 
they  disappear  under  antisyphilitic  treatment.  In  other  cases  a 
gumma  has  formed  a  round,  circumscribed,  nodular  swelling,  the 
size  of  a  walnut,  and  covered  with  ulcerated  mucous  membrane. 
The  ulcers  have  high  infiltrated  edges  and  a  grey  base.  The 
symptoms  resemble  those  of  a  new  growth.  There  is  hsematuria, 
sometimes  severe  and  terminal,  and  uninfluenced  by  rest.  There 
are  also  frequency  of  micturition  and  pyuria. 

Diagfnosis. — The  urine  must  be  examined  for  the  bacillus 
coli,  tubercle  bacillus,  and  other  bacterial  causes  of  cystitis  and 
ulceration.  The  history,  the  presence  of  signs  of  active  syphilis  or 
the  scars  of  postsyphilitic  affections,  and  the  effect  of  antisyphilitic 
treatment  without  local  treatment  are  important  in  diagnosis. 

Syphilitic  papilloma  and  gumma  disappear  rapidly  under 
treatment. 


xxxivj  VESICAL    ACTINOMYCOSIS  453 

LITERATURE 

Asch,  ZcUs.  /.   Urol,  1911,  p.  504. 

von  Englemann,  Folia  Urol.,  1911,  p.  472. 

Frank,    Vei-lKnulL  d.  II.  dents,  urol.  Kongress,  Berlin,  1909,  p.  356. 

Heberern,  Cculndbl.  /.  Chir.,  1911,  p.  063. 

Hinder,   Austral.  Med.  Gaz.,  1901,  p.  92. 

Lefur,  Vr  .Sess.  de  I'Assoc.  fran9.  d'Urol.,  1902,  p.  .'524. 

MacGowan,  Journ.  Cutati.  and  Gen.-Urin.  Vis.,  1901,  p.  642. 

Margoulies,  Ann.  d.  2Ial.  d.  Org.  Gen.-  IJrin.,  1902,  p.  384. 

ACTINOMYCOSIS  OF  THE  BLADDER 

Actinomycosis  very  rarely  affects  the  bladder,,  and  is  always 
secondary  to  intestinal  actinomycosis.  The  disease  reaches  the 
bladder  by  direct  continuity,  taking  origin  either  in  the  appendix 
or  in  the  rectum. 

Extensive  perivesical  inflammation  is  present  and  there  is 
usually  a  perivesical  abscess. 

The  symptoms  are  those  of  cystitis,  and  on  examination  there 
is  an  indurated  mass  in  the  perivesical  tissue  and  in  the  region  of 
the  appendix  or  round  the  rectum.  Malignant  growth  or  chronic 
appendicitis  may  be  diagnosed.  The  diagnosis  can  only  be  made 
by  the  discovery  of  the  yellow  actinomycotic  granules  in  the 
urine.  The  treatment  "consists  in  administering  large  doses  of 
iodide  of  potash  and  in  opening  collections  of  pus  if  they  exist. 
Iodides  have  not  proved  so  successful  as  was  at  one  time  antici- 
pated. If  the  bladder  is  invaded  the  cystitis  is  treated  by  urinary 
antiseptics  and  washing. 

LITERATURE 

Ruhrah,  Ann.  Surg.,  1899,  p.  417. 
Stanton,  Amer.  Med.,  1906,  p.  401. 


CHAPTER  XXXV 
TUMOURS  OF  THE  BLADDER 

Tumours  of  the  bladder  form  about  3  per  cent,  of  diseases  of  the 
urinary  organs  (Kiister).  Men  are  much  more  frequently  afiected 
(78  per  cent. — Albarran)  than  women.  In  children  vesical  growths 
are  rare,  and  are  usually  of  the  connective-tissue  varieties.  The 
age  most  frequently  affected  is  from  40  to  60  years.  Secondary 
growths  of  the  bladder  are  uncommon,  and  result  from  the  spread 
of  malignant  growths  from  the  prostate,  urethra,  or  rectum  in  the 
male,  and  from  the  uterus  in  the  female.  In  the  rare  papillo- 
matous tumours  of  the  renal  pelvis  or  ureter  papillomatous  new 
growths  may  become  implanted  on  the  bladder  mucous  mem- 
brane or  spread  from  the  ureteric  orifice. 

Etiology. — There  is  little  exact  knowledge  of  the  origin  of 
vesical  neoplasms.  The  frequent  situation  of  papillomatous 
growths  in  the  immediate  vicinity  of  the  ureteric  orifices  has  led 
to  the  view  that  some  irritant  in  the  urine  may  be  the  cause  of 
the  growth.  The  usual  position  is,  however,  above  and  to  the 
outside  of  the  ureteric  orifice,  while  the  stream  of  urine  is  directed 
downwards  and  inwards,  the  current  passing  just  below  the  orifice 
of  the  opposite  ureter. 

Workers  in  anihne  dyes  (fuchsin,  etc.)  are  stated  (Wendel, 
Lichtenstein)  to  be  especially  liable  to  the  development  of  papil- 
loma of  the  bladder,  and  this  is  ascribed  to  some  irritating  effect 
these  dyes  exert  upon  the  bladder  mucous  membrane.  Malignant 
growths  have  been  found  to  develop  in  a  bladder  the  seat  of 
long-standing  cystitis,  but  in  the  majority  of  cases  where  malig- 
nant disease  and  cystitis  are  combined  the  cystitis  occurs  as 
a  complication  of  the  growth.  In  40  per  cent,  of  malignant 
growths  spontaneous  cystitis  is  the  first  sign  of  disease.  A  malig- 
nant growth  may  develop  in  a  patch  of  leucoplakia  caused  by 
chronic  cystitis.  In  some  cases  of  chronic  cystitis  papillomatous 
masses  develop.  These  are  cystic  or  solid  (cystitis  cystica,  cystitis 
glandularis).  Stoerk  and  Zuckerkandl  have  traced  the  develop- 
ment of  glandular  carcinoma  of  the  bladder  from  cystitis  glandu- 
laris.    In  bilharzial  cystitis  the  development  of  papillomatous  and 

454 


CHAP.  XXXV]  VESICAL    GROWTHS  455 

malignant  new  growths  is  so  frequent  as  to  indicate  an  etiological 
relationship. 

Classification. — New  growths  of  the  bladder  are  conveniently- 
divided  into  the  following  groups  and  subgroups  : — 

1.  Epithelial   growths. 

(1)  Benign. 

(a)  Papilloma.     Villous  tumour. 

(6)  Adenoma. 

(c)  Cholesteatoma. 

(2)  Malignant. 

(a)  Papillomatous. 
Malignant  villous  growth. 
Nodular  growths. 

(b)  Infiltrating. 
Epithelioma. 
Adeno-carcinoma. 
Alveolar  carcinoma. 

2.  Connective-tissue  new  growths. 

(1)  Simple. 

(a)  Fibroma. 
(6)  Myoma.. 

(c)  Angioma. 

(2)  Malignant. 

(  Spindle-celled. 

Round-celled. 
Sarcoma    \  Melanotic. 

Rhabdo-myoma. 
^  Chondro-sarcoma. 

3.  Dernnoid  cysts, 

1.  EPITHELIAL    GROWTHS 

Papilloma — Villous  Tumour 

Pathology.— These  tumours  are  covered  with  villi  or  tendrils, 
and  are  either  spread  out  over  the  surface  of  the  mucous  mem- 
brane (sessile)  or  set  on  a  stalk  (pedunculated).  They  vary  in 
size  from  a  split  pea  to  a  Tangerine  orange,  and  may  be  single 
or  multiple  (30  to  40  per  cent. — Albarran).  The  great  majority 
are  situated  at  the  base,  in  the  neighbourhood  of  the  ureteric 
orifices,  usually  behind  and  to  the  outer  side  of  these  orifices, 
and  frequently  concealing  them.  They  are  rarely  situated  on  the 
trigone,  but  frequently  around  it,  and  they  may  surround  the 
urethral  orifice.  Other  parts  of  the  bladder  are  also  affected, 
especially  the  posterior  wall. 


456 


THE  BLADDER 


[chap. 


On  section  (Fig.  124)  a  papilloma  shows  a  central  fibrous  trunk 
with  branches  subdividing  in  all  directions.  Microscopically  the 
trunk  consists  of  fibrous  tissue  containing  elastic  and  plain  muscle 
fibres,  and  supporting  numerous  large  blood-vessels.  Each  branch 
and  twig  has  a  fibrous  core  containing  blood-vessels,  and  is  covered 
bv  a  thick  layer  of  epithelium  (Fig.  125).  This  consists  of  layers 
of  cells  of  the  tralisitional  epithelium  type.  The  deeper  cylindrical 
cells  radiate  from  the  core  in  characteristic  manner,  and  are  regular 
in  arrangement  and  size.     (Fig.  126.)     Where  the  villi  are  closely 


.-41m 


Fig.  124. — Slightly  magnified  section  of  operation  specimen 
of  papilloma  of  bladder. 

Two  papillomas  are  seen  with  villi  closely  packed  together.     The  relation  to  the  mucosa 
and  muscular  wall  of  the  bladder  is  shown. 

pressed  together  the  superficial  flat  cells  disappear  and  the  cylin- 
drical cell  layers  unite.  The  nuclei  show  karyokinetic  figures  in 
abundance.  Vacuolation  of  the  cells  and  the  formation  of  spaces 
containing  colloid  material  or  epithelial  debris  are  frequently 
observed.  (Edema  of  the  stroma  of  a  branch  may  result  from 
kinking.  The  tumour  may  consist  of  closely  set,  short  finger- 
like processes  (Fig.  127),  looking,  on  surface  and  section,  not 
unlike  a  cauliflower.  A  papilloma  may  remain  solitary  and  in- 
crease to  the  size  of  a  Tangerine  orange  ;  more  frequently  small 
villous  tumours  appear  around  the  parent  growth,  and  others  are 


XXXV]    VESICAL    PAPILLOMA:    PATHOLOGY      457 

dotted  over  the  bladder,  and  finally  the  cavity  may  be  filled  with 
masses  of  papillomatous  growth. 

Dilatation  of  the  ureter  and  kidney  on  the  side  corresponding 
to  the  growth  is  not  infrequent. 

The  histological  appearance  of  these  growths  is  benign,  but 
they  possess  certain  characters  by  which  they  differ  from  other 
benign  tumours. 


i.  They  may  spread  by  implantation.  A  portion  of  a  papil- 
loma of  the  kidney  may  be  detached  and  implanted  at  the  lower 
end  of  the  ureter  or  in  the  bladder.  Small  buds  of  papilloma 
appear  on  normal  mucous  membrane  around  the  parent  tumour. 
Recurrence  after  an  operation  shows  signs  of  implantation  of 
papillomas  in  the  track  leading  from  the  site  of  the  original  growth 
to  the  cystotomy  scar,  and  the  frequency  with  which  a  papilloma, 
usually  the  largest  of  the  recurrent  growths,  is  situated  at  the 
cystotomy  wound. 


458 


THE  BLADDER 


[chap. 


ii.  Recurrence  very  frequently  takes  place  after  removal,  and 
the  recurrent  growth  is  multiple  although  the  primary  growth 
may  have  been  single. 

iii.  The  recurrent  growths  after  operation  or  the  multiple 
papillomas  in  a  non-operated  bladder  become  sessile  and  irregular 
in  growth,  and  in  a  large  number  of  cases  eventually  infiltrate  the 
bladder  wall 

Symptoms. — Haematuria  is  the  characteristic,  and  usuallv  the 


Fig.  126. — Highly  magnified  villus  of  papilloma  of  bladder  with 
central  capillary  blood-vessel  and  covering  of  transitional 
epithelium. 

only,  symptom  of  papilloma  of  the  bladder.  It  appears  suddenly 
without  ascertainable  cause,  continues  for  one  or  two  micturitions 
or  for  a  day  or  a  week,  and  suddenly  ceases.  Rest  has  little  effect 
on  the  haemorrhage.  The  blood  is  copious,  and  mixed  throughout 
the  urine.  Occasionally  the  first  part  of  the  urine  is  blood-stained, 
and  a  few  drops  of  pure  blood  are  expelled  at  the  end  of  mic- 
turition. Flat  or  irregular  clots  may  be  present.  After  an  interval 
of  a  few  weeks,  but  more  often  of  several  months,  and  occasion- 
ally of  one  or  two  years,  another  attack  of  haemorrhage  occurs 
similar  in  character  and  duration  to  the  first ;  and  this  recurs  with 
diminishing  intervals,  and  often  with  increasing  duration  of  the 


XXXV]  VESICAL  PAPILLOMA  :  COMPLICATIONS  459 


hajmorrhage.  The  hsemorrhage  comes  from  a  ruptured  vessel  in 
a  villus,  and  clot  may  be  seen  adhering  when  the  hematuria  has 
ceased. 

SUght  aching  pain  in  one  kidney  is  frequently  present  if 
the  papilloma  is  situated  in  the  neighbourhood  of  one  ureter. 
Occasionally  other  symptoms  are  added.  A  patient  under  my 
care  had  an  attack  of  intense  pain 
and  strangury,  with  the  discharge  of  a 
few  drops  of  bright  blood  from  the 
urethra  every  few  minutes.  A  pedun- 
culated papilloma  had  engaged  in  the 
prostatic  urethra  and  caused  spasm  of 
the  bladder.  Another  patient  with  a 
pedunculated  papilloma  had  five  at- 
tacks of  retention  of  urine  from  plug- 
ging of  the  internal  meatus. 

Complications. — Profound  anaemia 
from  recurrent  haemorrhages  is  not  in- 
frequent. Spontaneous  cystitis  is  very 
rare,  but  cystitis  very  often  follows 
the  introduction  of  instruments,  espe- 
cially in  cases  of  pedunculated  papil- 
loma, where  some  degree  of  urethral 
obstruction  from  plugging  is  usually 
present. 

Cystitis  leads  to  sloughing  of  por- 
tions of  the  growth,  to  the  deposit  of 
phosphates  on  the  growth,  and  occa- 
sionally to  the  formation  of  stone. 

Retention  of  clot  from  excessive 
haemorrhage  is  rare.  Retention  of  urine 
may  occur  from  a  pedunculated  papil- 
loma obstructing  the  internal  meatus. 

Course  and  prognosis. — The  dura- 
tion of  papilloma  of  the  bladder  may 
extend  over  many  years  (ten  to  fif- 
teen, even  twenty-five) ;  meanwhile  the 
growth  increases  in  size  and  forms  a  large  single  tumour,  or 
multiplies  and  covers  large  areas  of  mucous  membrane.  It  may 
very  rarely  remain  quite  stationary  for  many  years,  and  I  have 
seen  a  case  of  multiple  recurrent  papillomas  in  which  the 
growths  slowly  diminished  in  size  during  seven  years  and  have 
almost  disappeared. 

The  average  duration  of  life  after  the  appearance  of  symptoms 


Fig.  127. — Papillomas  of 
bladder,  removed  by 
operation. 

At  the  upper  part  of  each  drawing  is 
a  portion  of  the  mucous  membrane 
and  muscle  of  the  bladder  wall,  re- 
moved with  the  tumour. 


460  '  THE  BLADDER  [chap. 

is  stated  to  be  about  three  years.  In  my  experience  it  is 
much  longer.  Recurrence  of  growth  after  operation  is  very 
common,  and  is  due  to  (a)  new  development  of  papilloma  from 
the  original  cause,  (6)  incomplete  operation,  (c)  implantation  of 
fragments  in  the  bladder  wall  during  removal. 

Malignant  transformation  is  frequent,  and  may  occur  in  un- 
operated  or  in  recurrent  growths.  However  benign  the  histo- 
logical characters  of  the  original  papilloma  may  be,  clinical 
experience  shows  that  recurrence  after  removal  is  very  common, 
and  that  infiltration  of  the  bladder  wall  occurs  eventually  in  a 
large  proportion  of  cases.  Papilloma  of  the  bladder  cannot,  there- 
fore, be  looked  upon  as  a  benign  tumour,  and  it  is  better  to 
regard  it  as  a  precancerous  condition  in  all  cases. 

Diagfnosis. — "  Symptomless  "  hsematuria  in  a  young  or  middle- 
aged  adult  is  usually  due  to  papilloma  of  the  bladder,  to  "  essen- 
tial renal  heematuria,"  or  to  early  renal  growth.  If  tube  casts 
are  present  the  condition  is  renal.  The  quantity  and  appearance 
of  the  blood  may  be  the  same  in  all  three  conditions.  The  passage 
of  fragments  of  papillomatous  growth  in  the  urine  is  important 
but  rare.  It  is  impossible  to  distinguish  by  the  microscope  be- 
tween fragments  from  papilloma  of  the  bladder  and  from  similar 
tumours  in  the  renal  pelvis  or  ureter,  but  the  passage  of  papillo- 
matous masses  from  the  kidney  almost  invariably  gives  rise  to 
ureteral  colic,  and  these  papillomas  are  very  rare.  Evidence  may 
also  be  obtained  by  the  removal  of  portions  of  growth  in  the  eye 
of  a  catheter. 

Histologically  there  may  be  nothing  to  show  whether  the 
portion  of  papilloma  has  been  detached  from  a  benign  papilloma 
or  from  the  surface  of  a  malignant  growth. 

Palpation  of  the  bladder  from  the  rectum  and  bimanually 
gives  negative  results  in  the  great  majority  of  papillomas,  but 
when  the  growth  is  large  and  firm  it  can  be  felt  in  bimanual 
palpation  in  favourable  cases.  The  diagnosis  can  only  be  certain 
when  the  cystoscope  is  used. 

Cystoscopy. — Cystoscopy  for  symptomless  hgematuria  should 
be  made  during  an  attack  of  bleeding,  for  should  the  haemorrhage 
prove  to  be  renal  it  will  be  seen  from  which  ureter  the  blood  is 
issuing.  When  the  haemorrhage  arises  from  a  vesical  papilloma 
there  is  seldom  difficulty  in  obtaining  a  clear  medium. 

A  papilloma  is  seen  as  a  round  or  irregular  tumour  with 
tendrils  of  varying  length  which  float  in  the  fluid  and  are  stirred 
by  every  current  or  eddy.  (Plate  32,  Fig.  3.)  They  may  resemble 
the  fronds  of  a  luxuriant  fern  or  ostrich  feathers,  or  they  may  be 
short  and  leaf -like  and  the  tumour  may  be  like  a  coarse  bath  sponge. 


XXXV]    VESICAL    PAPILLOMA:    TREATMENT       461 

Each  villus  has  a  fine  central  vessel  with  lateral  branches.  The 
majority  of  papillomas  have  a  short  pedicle  (subsessile),  some  have 
a  long  delicate  stalk  (pedunculated),  and  others  are  sessile.  The 
tumour  is  most  frequently  situated  on  the  upper  and  outer  aspect 
of  the  ureteral  orifice,  which  may  be  hidden  by  its  branches. 
Usually  a  leash  of  vessels  passes  up  to  the  growth  from  the  trigone. 
Small  buds  of  papilloma  may  be  found  on  the  mucous  membrane 
in  the  neighbourhood,  and  other  papillomas  may  be  scattered 
about  the  bladder.  Adherent  clots  appear  as  dark-red  or  black 
masses,  and  the  tumour  may  be  powdered  with  phosphates. 

When  the  growth  is  very  large  the  beak  of  the  cystoscope 
may  plunge  into  it,  and  the  light  is  obscured  so  that  no  view 
is  obtained. 

Treatment.  Non-operative. — Prolonged  treatment  by  wash- 
ing the  bladder  with  solutions  of  nitrate  of  silver  and  resorcin 
with  the  object  of  causing  necrosis  of  the  tumours  has  been  advo- 
cated by  Casper,  Herring,  and  others.  Daily  instillations  of  2  oz. 
of  nitrate  of  silver  solution  (1  in  3,500  at  100°  F.)  are  made  by 
means  of  a  catheter  and  retained  for  a  few  seconds,  and  then 
repeated  once.  The  instillations  are  best  made  at  night,  and  the 
patient  feels  only  a  slight  warmth  for  half  an  hour.  The  strength 
of  the  solution  is  gradually  increased  to  1  in  1,000,  and  the  treat- 
ment continues  for  six  months. 

Solutions  of  resorcin  (2  per  cent,  up  to  10  per  cent.)  have  also 
been  used  bi-weekly.  This  method  has  apparently  met  mth  an 
occasional  success  or  partial  success.  It  may  be  useful  in  cases 
which  are  unsuitable  for  operation,  or  which  have  recurred  and 
are  still  small. 

Radium  and  the  high-frequency  current  (fulguration)  are  under 
trial.  Radium  is  inserted  in  a  catheter  into  the  bladder  and  a 
radium  plate  applied  suprapubically,  or  radium  may  be  suspended 
in  the  rubber  drainage  tube  after  suprapubic  operation  as  a 
prophylactic  measm'e.  For  high-frequency  treatment  an  electrode 
is  applied  to  the  growth  through  a  catheterizing  cystoscope,  a  flat 
electrode  being  applied  suprapubically. 

Operative  treatment,  (o)  Removal  through  the  urethra.  "  In- 
travesical operations.'''' — This  is  carried  out  by  means  of  the  Nitze 
operating  cystoscope  (or  some  modification  of  it),  or  by  Luys' 
direct  cystoscope,  or  in  the  female  through  Luys'  or  Kelly's  cysto- 
scope. A  fine  platinum  wire  is  projected  from  a  tunnel  in  view 
of  the  cystoscope  ^^dndow  and  is  passed  over  the  tumour,  which 
is  snared  and  left  in  the  bladder  to  be  expelled  in  the  urine.  If 
the  papilloma  is  very  large,  portions  of  it  are  removed  at  several 
sittings.     Hemorrhage    is    sometimes    severe    after    these    opera- 


462 


THE  BLADDER 


[chap. 


tions.  The  growths  must  be  favourably  situated.  Tumours  near 
the  neck  of  the  bladder  are  unsuitable.  Those  at  the  base  and 
on  the  posterior  wall  are  most  suitably  placed. 

With  the  direct  cystoscope  the  growth  can  be  touched  with 
the  electric  cautery,  or  removed  with  forceps  or  a  snare  and  the 
base  cauterized. 

Malignant  growths  should  not  be  operated  on  by  this  method. 
The  advantages  claimed  for  it  are  the  small  mortality,  the  avoid- 
ince  of  complications  such  as  sepsis,  fistula,  phlebitis,  or  pneu- 
monia, the  ability   of 
the  patient  to  continue 
work,    the    avoidance 
of  danger  of  implant- 
ing tumour  cells,  and 
its  greater  applicabihty 
to  recurrent  tumours. 
The     Open     operation 
applied  to  cases  suit- 
able   for    intravesical 
removal   should,  how- 
ever,   have    no    mor- 
tality ;     complications 
such    as    those    men- 
tioned      should       not 
occur    with    thorough 
aseptic  operation,  and 
the  after-treatment  of 
the    bladder     {see    p. 
465)     should    prevent 
any  possibility  of  im- 
plantation. Very  small 
recurrent  growths  may 
be   treated    by    intra- 
vesical   removal,     but 
the  tendency  of  recur- 
rent growths  to  become 
malignant     must     be 
remembered.     Good  results  in  small  growths  have  been  obtained 
by  some  surgeons.     Weinrich  found  that  71  cases  out  of   101  oper- 
ated before  1902  had  no  recurrence.     There  were  18  cases  of  re- 
currence, and  12  cases  were  untraced.    The  mortality  was  1  in  150. 
(6)  Removal  hy  open  operation. — This  is  the  most  radical  form 
of  treatment,  and,  in  view  of  the  pathology,  should  be  adopted 
in  all  cases  when  no  contra-indication  to  an  operation  exists.     If 


Fig.  128. — Gystoscopic  chart  of  multiple 
papilloma  of  bladder. 

The  trigone  with  ureteric  and  urethral  orifices  is  shown,  and 

the  number  and  position  of  the  growths.     At  X  a  small  paoil- 

loma  was  concealed  from  the  view  of  the  cystoscope  behind 

the  larger  growth. 


XXXV]     VESICAL    PAPILLOMA:    OPERATION 


463 


multiple  papillomas  are  present  a  chart  showing  their  number 
and  position  must  be  drawn  at  a  preliminary  cystoscopy.  (Figs. 
128,  129.) 

Suprapubic  cystotomy  is  performed  by  a  vertical  median  in- 
cision 3  in.  in  length,  the  peritoneum  being  pushed  aside.  The 
edges  of  the  bladder  wound  are  held  by  two  catgut  traction  sutures, 
and  the  patient  is  placed  in  the  Trendelenburg  position.  Suit- 
able bladder  retractors 
(Fig.  130)  are  intro- 
duced, a  small  re- 
tractor being  placed 
on  the  side  of  the 
growth  and  a  large 
one  on  the  opposite 
side.  With  a  power- 
ful head-lamp  the  in- 
terior of  the  bladder  is 
thoroughly  examined. 
A  solitary  peduncu- 
lated   papilloma   (Fig. 

131)  is  picked  up  with 
forceps,  the  pedicle  put 
on  the  stretch,  and  a 
double  catgut  suture 
passed  through  it  and 
tied.  The  pedicle  is 
then  cut  through,  and 
with  it  an  area  of 
bladder  mucous  mem- 
brane which  was  raised 
by  the  traction.  In 
sessile  papilloma  (Fig. 

132)  the  mucous  mem- 
brane is  raised  and  cut 
through  half  an  inch 
from  the  tumour,  and 
the  incision  carried 
round  it  at  this  dis- 
tance, so  that  a  good 
margin  of  healthy  mu- 
cous membrane  is  re- 
moved with  the  growth 
(Fig.  133).  The  mu- 
cous membrane  is  then 


Fig.     129. — Cystoscopic     chart 
of  recurrent  papillomas   of 
the  bladder. 

The  largest  growth  is  in  the  position  of 
the  suprapubic  scar. 


Fig.  130.— Author's 
bladder  retractors. 


464 


THE   BLADDER 


[chap. 


brought  together  and  bleeding  controlled  by  catgut  stitches.  I 
use  special  needles  on  pliable  handles  (Fig.  134),  long  fine  for- 
ceps (Fig.  135),  and  curved  scissors  (Fig.  136)  for  these  opera- 
tions. If  a  number  of  papillomas  are  situated  close  together 
the  whole  area  of  mucous  membrane  bearing  them  is  removed 


Fig.  131. — Removal  of  pedunculated  papilloma  of  bladder. 

The  patient  is  in  the  Trendelenburg  position,  and  the  edges  of  the  suprapubic  cystotomy  wound 

are  widely  retracted.     The  papilloma  is  grasped  with  long  forceps,  and  the  base  of  the  pedicle  is 

transfixed  by  a  needle  with  catgut. 

in  one"  strip  (Fig.  137).  I  have  removed  an  area  as  large  as 
the  palm  of  the  hand,  and  in  one  case  half  the  mucous  mem- 
brane of  the  bladder  was  stripped  off.  When  the  papilloma  lies 
near  the  orifice  of  the  ureter  a  catheter  should  be  passed  up  the 


XXXV]    VESICAL  PAPILLOMA:    OPERATION 


465 


duct  in  case  it  may  be  included  in  the  stitches.  Great  care  is 
taken  not  to  soil  the  mucous  membrane  by  contact  ^\■ith  the 
papilloma  during  removal.     At  the  end  of  the  operation  I  treat 


Fig.  132. — Removal  of  multiple  sessile  papilloma  of  bladder, 

A  traction  suture  steadies  and  raises  the  mucous  membrane  on  the  near  side  of  the  papilloma. 

The  mucous  membrane  is  cut  round  the  base  of  the  growth  with  long  curved  scissors  and  dissected 

up,  carrying  with  it  the  growth.     The  cut  edges  of  mucous  membrane  are  united  with  catgut.     On 

the  right  is  a  wound  already  closed. 

the  bladder  with  silver  nitrate  solution  5  or  6  per  cent.,  formalin 
1  in  300,  resorcin  10  per  cent.,  or  other  albumin  coagulant,  with 
the  object  of  destroying  stray  cells   or  microscopic   papillomas. 

9  w 


466 


THE  BLADDER 


[chap. 


The  bladder  is   drained  through   a   large   suprapubic  tube,    and 
washed  daily  with  weaker  solutions  of  these  drugs. 

The  suprapubic  wound  may  be  closed  at  the  end  of  the  opera- 
tion with  catgut  sutures  and  a  catheter  placed  in  the  urethra,  but 


Fig.  133. — Group  of  papillomas  removed  from  bladder. 

The  tumours  are  removed  with  an  area  of  mucous  membrane,  which  shrinks  after  removal.     In 

two  the  under  surface  is  shown.     An  area  of  mucous  membrane  bearing  eight  separate  tumours 

is  seen  at  the  upper  left-hand  corner. 

if  this  is  done  the  treatment  of  the  bladder  with  strong  solutions 
must  be  omitted.  Complete  immediate  suture  of  the  bladder  with 
catheter  drainage  may  even  in  the  simplest  operation  for  papilloma 
lead  to  haemorrhage  which  necessitates  opening  up  the  suprapubic 


XXXV]     VESICAL   PAPILLOiMA:    OPERATION        467 

wound,  and  I  have  now  abandoned  it  and  diain  every  case  supra- 
pubically. 

In  removing  the  papillomas  a  Guyon's  clamp  may  be  used, 


Fig.  134. — Author's  needle  on  pliable 
handle  for  bladder-growth  operations. 


but  it  is  rarely  necessary,  and  may  injure  the  ureteric  orifice. 
After  convalescence  the  bladder  should  be  examined  at  regular 
intervals  wnth  the  cystoscope  for  recurrence. 

In  its  earliest  stage  a  recurrent  bud  of  papilloma  should  be 
treated  by  a  fine  electric  cautery  applied  through  a  Luys'  cysto- 


BBflllHlpn 

Fig.   135. — Long  toothed  and  serrated  forceps  for  bladder- 
growth  operations. 

scope,  or  instillation  of  nitrate  of  silver  may  be  tried.  If  the 
recurrent  tumour  is  large  or  multiple  a  second  suprapubic  opera- 
tion is  necessary. 

When  the  bladder  cavity  is  filled  with  large  numbers  of  papillo- 
matous growths  the  operations  described  are  inapplicable.     The 


Fig.   136. — Long  curved  scissors  for  bladder-growth  operations. 

choice  then  lies  between  palliative,  non-operative  treatment,  and 
operative  treatment.  Operative  treatment  consists  in  (1)  open- 
ing the  bladder  and  clearing  out  the  contents,  and  stopping  the 
bleeding  by  means  of  the  cautery,  hot  douche,  nitrate  of  silver, 


468 


THE  BLADDER 


[chap. 


adrenalin,  or,  better,  packing  the  bladder  with  gauze  round  a 
large  rubber  tube  which  leads  down  to  the  ureters  ;  or  (2)  the  total 
removal  of  the  bladder  (cystectomy)  after  ureterostomy.  The 
latter  operation  has  a  high  immediate  and  remote  mortality,  but 
it  is  the  only  method  by  which  cure  can  be  obtained  in  these 
cases. 

Transperitoneal    cystotomy    has    been    advocated    (Harrington, 
Mayo)  as  an  easier  method  of  approach  in  operating  on  papilloma 


Fig,  137. — Papilloma  of  bladder. 

Numerous  discrete  papillomas,  and  one  large  area  of  mucous  membrane  covered  with  papillomatous 

masses.     The  extent  of  this  portion  of  mucous  membrane  was  half  the  posterior  and  the  whole 

of  the  left  lateral  wall  of  the  bladder. 

of  the  bladder.  This  method  is  unnecessary,  as  there  is  no 
difficulty  in  obtaining  full  exposure  and  room  for  manipulation  by 
the  ordinary  extraperitoneal  route. 

Palliative  treatment. — In  cases  in  which  radical  operation  is 
abandoned,  certain  complications  and  symptoms  may  arise  which 
require  treatment. 

Hcemorrhage. — Unless  the  case  is  acknowledged  to  be  inoperable, 


XXXV]     VESICAL   PAPILLOMA:    PALLIATION       469 

the  proper  treatment  for  hsemorrhage  is  early  removal  of  the 
growth,  and  the  less  the  bladder  is  interfered  ^\^lth  before  the 
operation  the  better.  Haemorrhage  so  severe  as  to  cause  acute 
anaemia  seldom  occurs.  The  patient  is  kept  in  bed  and  a  morphia 
suppository  (J  gr.)  or  a  hypodermic  injection  of  morphia  {^-l  gr.) 
given.  Calcium  lactate  in  doses  of  10  or  15  gr.  every  four  hours 
is  given  for  two  days,  but  if  haemorrhage  persists  beyond  this 
time  it  is  then  omitted.  Ergot,  iron  salts,  tannin,  acetate  of  lead, 
and  suprarenal  extract  given  internally  have  all  been  used,  but 
in  my  experience  they  are  worthless.  Washing  the  bladder  should 
be  avoided  if  possible,  as  there  is  a  very  serious  risk  of  intro- 
ducing sepsis.  Should  it  become  necessary,  a  large  coude  catheter 
(10  or  12  Fr.)  should  be  passed  under  the  strictest  aseptic  pre- 
cautions and  the  bladder  washed  out  by  means  of  an  irrigator. 
About  4  or  6  oz.  are  allowed  to  run  in  and  to  escape,  and  this 
is  repeated  until  several  pints  have  been  used.  The  best  solution 
is  silver  nitrate,  1  in  10,000,  and  it  should  be  used  hot  (110°  to 
120°  F.). 

Another  method  is  to  pass  a  double-way  catheter  and  run  a 
continuous  stream  of  hot  silver  nitrate  solution  through  the 
bladder.  A  weak  solution  of  adrenalin  (1  in  100,000)  may  be 
used,  but  it  is  not  so  efficacious. 

Instillations  of  stronger  solutions  may  be  used,  such  as  silver 
nitrate  solution  (3  oz.  of  l-in-1,000  or  l-in-500  solution)  or  adrenalin 
(1  oz.  of  l-in-2,000  solution).  These  are  allowed  to  remain  in 
the  bladder  for  a  few  minutes  and  then  run  off.  The  following 
may  also  be  used,  viz.  3  oz.  of  a  sterilized  solution  of  gelatin  (2  per 
cent.),  or  2  oz.  of  creolin  solution  (J-1  per  cent.)  at  a  temperature 
of  105°  F.,  retained  for  twenty,  or  thirty  minutes. 

If  clotting  has  occurred  in  the  bladder  the  clots  are  extracted 
with  a  large  evacuating  cannula  with,  rubber  bulb,  such  as  is  used 
in  litholapaxy.  This  method  should  be  employed  with  the  utmost 
caution  and  under  strict  aseptic  conditions,  and  should  not  be 
persisted  in  if  it  is  not  at  once  successful.  After  removal  of  the 
clots  a  large  catheter  should  be  fixed  in  the  urethra  and  the 
bladder  washed  frequently  with  normal  saline  solution  to  prevent 
recurrence  of  clotting,  or  a  double-way  catheter  and  continuous 
irrigation  with  normal  saline  solution  should  be  installed.  Finally, 
should  these  methods  fail,  the  bladder  should  be  opened  supra- 
pubically,  the  clots  cleared  out,  and  a  large  rubber  tube  inserted. 

Bladder  spasm. — In  the  later  stages  of  recurrent  and  inoper- 
able papilloma  and  in  infected  cases  there  may  be  distressing 
frequency  of  micturition  and  painful  spasm  of  the  bladder.  The 
general  and  local  treatment  for  cystitis  should  be  carried  out. 


470  THE   BLADDER  [cHAr. 

Instillations  into  the  bladder  of  a  few  ounces  of  distilled  water 
containing  antipyrin  (2  per  cent.)  and  laudanum  (1  per  cent.), 
or  of  orthoform  (5  to  10  per  cent.),  or  the  use  of  suppositories 
containing  belladonna  (J  gr.)  and  morphia  (^-^  gr.)  or  lupulin 
(4  gr.),  may  give  temporary  relief. 

The  injection  of  20  or  30  minims  of  sterilized  water,  or  eucaine 
(2  per  cent.)  or  cocaine  (1  per  cent.),  into  the  sacral  canal  may 
also  assist  {see  p.  383). 

Permanent  suprapubic  drainage  may  become  necessary,  and 
the  opportunity  may  be  taken  to  clear  out  the  papillomatous 
material  and  apply  nitrate  of  silver  solution. 

In  some  cases  the  pain  and  spasm  continue  in  spite  of  this, 
and  nephrostomy  or  permanent  drainage  of  the  kidneys,  or  ureter- 
ostomy, by  bringing  the  ureters  to  the  surface  in  the  loin  or  groin; 
may  be  necessary  in  order  to  direct  the  urine  from  the  hyper- 
sensitive organ. 

Results. — The  mortality  of  open  radical  operations  on  papil- 
loma of  the  bladder  is  very  small  under  modern  conditions.  Rafin 
found  a  mortality  of  3-8  per  cent,  in  156  cases  operated  on  in 
recent  years.  Recurrence  of  papilloma  after  operation  is  fre- 
quent. In  Rafin's  collection  there  were  33  cases  of  recurrence 
out  of  115  cases  traced  (28  per  cent.).  In  18  cases  there  was 
no  recurrence  for  over  three  years,  and  non-recurrence  was  re- 
ported in  periods  as  long  as  fourteen  and  twenty  years.  Recur- 
rence four  and  eight  years  after  operation  has  been  recorded. 
The  recurrent  tumours  are  usually  multiple,  and  may  have  the 
same  characters  as  the  primary  growth.  There  is  a  marked 
tendency,  however,  for  the  type  to  change.  The  tumour  becomes 
more  and  more  sessile,  the  villi  shorter,  and  the  surface  smoother, 
and  finally  infiltration  of  the  submucous  and  muscular  coats 
takes  place. 

Watson  found  that  about  60  per  cent,  of  pedunculated  papil- 
lomas were  cured  by  operation,  but  only  2  per  cent,  of  sessile 
and  multiple  papillomas.  The  number  of  cases  of  recurrence  will, 
I  hold,  be  greatly  reduced  by  careful  preoperative  charting 
of  multiple  growths,  by  thorough  operation,  and  by  treatment  of 
the  bladder  with  strong  solutions  after  the  operation. 

Adenoma 
Adenoma  is  a  rare  tumour  so  far  as  the  bladder  is  concerned. 
It  arises  in  the  glands  in  the  region  of  the  base  of  the  bladder, 
and  is  found  in  two  forms,  a  diffuse  and  a  circumscribed  (Rochet 
and  Martel).  The  tumours  have  a  smooth  or  villous  surface. 
Rafin  collected  11  operated  cases. 


XXXV]  VESICAL   CARCINOMA  471 

Cholesteatoma 

This  rare  condition  was  described  hy  Rokitansky,  and  10 
cases  were  collected  from  the  literature  by  Rafiii.  There  is  great 
thickening  of  the  epitheUum,  which  becomes  squamous  and  pre- 
sents a  pearly  appearance.  Masses  of  epithelial  debris  are  thrown 
off  and  collect  on  the  surface.  The  whole  urinary  tract  may  be 
affected. 

Carcinoma 

A  number  of  malignant  growths  differing  widely  in  their  gross 
and  microscopic  characters  are  grouped  under  this  heading. 

The  following  grouping  of  varieties  is  cHnical,  and  will  be  of 
greater  use  to  the  surgeon  than  a  strictly  pathological  classification  : 

(1)  Malignant  Papilloma 

However  benign  the  macroscopic  appearances  of  a  villous 
growth  of  the  bladder  may  be,  the  majority,  as  already  stated, 
eventually  become  malignant  if  untreated.  Some  papillomas  are 
malignant  from  their  earliest  stage  of  development.  Macro- 
scopically,  malignant  papillomas  may  be  similar  in  appearance 
to  those  of  benign  form,  but  certain  characters  can  usually  be 
detected.  The  villi  are  more  stunted  and  less  regular  in  size 
and  shape,  the  tumour  is  sessile  and  irregular  in  contour.  In- 
filtration of  the  bladder  wall  commences,  and  the  mucous  mem- 
brane at  the  base  is  thickened  and  adherent  to  the  submucous 
tissue.  Microscopically  the  epithelial  cells  show  rapid  and  very 
irregular  proliferation.  The  base  shows  the  invasion  of  lymphatic 
spaces  and  veins  by  irregular  masses  of  cells.  Another  type  of 
malignant  papilloma  is  malignant  from  its  earliest  appearance. 
The  growth  is  very  rapid  and  irregular,  and  luxuriant  on  the 
surface,  so  that  the  bladder  is  rapidly  filled  with  a  friable  mass 
from  which  portions  slough  oft'  and  are  discharged  in  the  urine. 

(2)  Nodular  Growths 

These  are  sessile,  or  rarely  have  a  short  pedicle,  and  vary  in 
size  from  a  hazel-nut  to  a  chestnut  or  a  Tangerine  orange.  The 
surface  may  be  irregular  with  nodules  varying  in  size,  or  there 
may  be  a  large  single  mass  with  a  regular  nodular  surface.  Occa- 
sionally there  is  a  round  tumour  with  flat  surface,  the  centre  of 
which  is  depressed  and  shows  short  villi,  with  sometimes  a  hard, 
brown,  pigmented,  calcareous  mass  adherent  to  it.  The  margin 
is  rounded  and  vertically  ridged.     (Plate  33,  Figs.  1,  2,  3.) 

These  tumours  belong  to  the  papillomatous  group.  (Fig.  138.) 
The  surface  consists  of  a  dense  mass  of  irregvilar  villi  closely  welted 


472 


THE  BLADDER 


[chap. 


together,  and  sometimes  necrotic  on  the  surface  about  the  centre. 
In  the  deeper  part  there  is  a  fine  stroma  of  fibrous  tissue  sup- 
porting irregular  spaces  filled  with  cells.     In  these  spaces  papillary 


^'M  ^m.  ^'^f  C    ^gv-^f'..^  #^i 


Fig.  138. — Microscopical  section  of  a  nodular  malignant 
growth  (papillomatous  variety). 

formations    are   frequently   seen.     Masses    of   cells   infiltrate    the 
muscular  planes  passing  along  the  lymphatic  vessels. 

(3)  Infiltrating  Growths 

The  growth  forms  fiat  nodules  on  the  surface  of  the  mucosa, 
but  its  most  extensive  growth  is  intramural.  Not  infrequently 
it  takes  the  form  of  a  hard,  depressed  ulcer  surrounded  by  nodules 
or  by  a  raised,  hard  ring  of  growth.  (Plate  34.)  The  histological 
structure  varies. 

(a)  Squamous  epithelioma  {chancroid). — This  takes  origin  in  a 
patch  of  leucoplakia  (Fig.  139).     The  greatly  thickened  and  heaped. 


X 


Figs.  1,  2,  3. — Views  of  operation  specimen  of  malignant  growth  of  bladder  (nodular 
papilloma).  On  surface  is  a  mass  of  clot  encrusted  with  phosphates.  The 
third  figure  shows  peritoneal  surface.     (Pp.  473-8.) 

Fig.  4. — Recurrence  of  malignant  growth  of  bladder  in  scar  of  resection  wound. 
Operation  specimen  of  second  operation.  Patient  well  three  and  a  halt  years 
later.     Primary  tumour,  sec  Plate  35,  Fig.  3.     (P.  485.) 


Plate  33. 


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xxxv] 


MALIGNANT  GROWTHS 


473 


up  epithelium  infiltrates  the  submucous  tissue  and  a  depressed 
ulcer  is  formed.  The  growth  has  the  structure  of  a  squamous 
epithehoma  with  cell  nests.     (Figs.  140,  141,  and  Plate  34.) 

(6)  Cylindrical  epithelioma  or  adeno-carcinoma  consists  of  round 
or  oval  spaces  lined  with  one  or  two  layers  of  cylindrical  epithehum. 
These  tumours  develop  at  the  base  of  the  bladder,  and  are  com- 
paratively rare.  Stoerk  and  Zuckerkandl  have  shown  the  close 
relation  between  this  form  of  growth  and  cystitis  glandularis. 

(c)  Alveolar  carcinoma. — Alveoli  of  varying  sizes,  branching  and 


Fig.  139. — Leucoplakia  of  mucous  membrane  in  neighbourhood 
of  large  squamous  epithelioma  of  bladder. 

Note  the  presence  of  papillae  and  the  large,  clear,  flat  nucleated  cells. 

tubular,  filled  with  cells  of  varying  shape  and  size,  many  of  which 
are  cylindrical  and  others  spheroidal,  are  set  in  a  stroma  of  con- 
nective tissue.  The  proportion  of  the  cellular  elements  to  the 
stroma  varies.  With  an  excessive  development  of  the  former 
a  soft  tumour  is  formed,  while  a  highly  developed  stroma  forms 
a  scirrhus.  When  stroma  and  cellular  elements  are  equally 
balanced  it  is  customary  in  German  literature  to  term  the  growth 
"  carcinoma  simplex." 

Spread  of  growths  of  the  bladder. — Growths  remain  for  a 
long  time  localized  in  the  bladder.  The  spread  is  intravesical, 
intramural,  perivesical,  glandular,  and  metastatic. 

The    intravesical    spread    of    papillomatous    growths    may    be 


474 


THE   BLADDER 


[chap. 


rapid  and  extensive.  It  appears  to  take  place  by  implantation, 
small  papillomas  occurring  on  the  mucous  membrane  around  the 
original  tumour.  After  removal  of  a  papilloma  recurrence  takes 
place  in  a  form  which  also  suggests  implantation.  A  track  of 
papillomas  is  seen  from  the  site  of  the  original  growth  to  the  supra- 
pubic scar,  and  the  largest,  and  occasionally  the  only,  recurrent 
tumour  is  situated  on  the  vesical  aspect  of  the  cystotomy  scar. 


Fig.  140. — Section  of  squamous  epithelioma  of  bladder 
showing  cell  nests.     {See  Plate  34.) 

Propagation  by  contact  is  occasionally  seen  in  malignant  growths 
of  the  bladder.  A  small  secondary  growth  develops  on  the  por- 
tion of  the  bladder  wall  which  comes  in  contact  with  the  parent 
tumour  when  the  viscus  is  empty.  The  anterior  and  superior 
walls  are  those  affected  in  this  manner.     (Fig.  141.) 

Owing  to  the  peculiar  distribution  of  the  lymphatic  vessels 
{see  p.  348)  malignant  growths  may  spread  widely  in  the  muscular 
coat  while  their  extent  is  still  limited  in  the  mucous  and  sub- 
mucous layers.     Rapid  penetration  of  the  growth  through  all  the 


XXXV]    MALIGNANT   GROWTHS:    SYMPTOMS      475 

coats  of  the  bladder  wall  is  a  feature  in  some  tumours  which  do 
not  spread  laterally. 

The  perivesical  spread  is  sometimes  as  extensive  as  the  intra- 
vesical growth,  and  this  ])art  of  the  growth  is  surrounded  by 
dense  fibrous  fat.  Adhesions  to  the  vagina,  uterus,  rectum,  and 
intestines  take  place  in  the  later  stages,  and  perforation  may  occur. 
The  spread  along  the  lymphatics  follows  the  large  trunks  {see 
p.  348).  The  first  glands  are  a  few  small  lymph  nodules  in  the 
outer  coat  of  the  bladder,  and  then  the  larger  lymph -glands 
serving  the  different  regions  of  the  bladder  are  affected.  Pasteau 
states  that  the  glands  along  the  internal  iliac  arteries  are  affected 


Fig.   141. — Small  epitheliomatous  ulcer  (contact  growth) 
on  anterior  wall  of  bladder. 

There  was  an  extensive  nodular  malignant  growth  at  the  base. 

in  79  per  cent,  and  the  lumbar  glands  in  26  per  cent,  of  cases. 
This  refers  to  the  advanced  stage  found  post  mortem. 

In  the  latest  stages  secondary  deposits  may  be  found  in  the 
lung,  pleura,  liver,  spleen,  or  kidney. 

Symptoms. — The  onset  of  symptoms  is  usually  insidious ; 
occasionally  there  is  a  sudden  severe  attack  of  hsematuria  with- 
out previous  symptoms. 

Haematuria  is  the  most  frequent  (90-2  per  cent,  of  cases)  and 
the  earliest  (61-7  per  cent.)  symptom.  The  bleeding  usually  com- 
mences gradually.  A  little  blood  appears  at  the  end  of  micturi- 
tion. This  passes  off,  and  reappears  and  increases  till  the  whole 
urine  is  stained.  Clots  are  frequently  present  (34  per  cent.). 
Persistent  slight  terminal  haematuria  may  be  observed,  with 
occasional  attacks  of  severe  haemorrhage. 

Frequent  micturition  occurs  in  68  per  cent,  of  cases,  and  may 
be  the  first  symptom  (14-7  per  cent.).     It  is  nocturnal  as  well  as 


476  THE   BLADDER  [chap. 

diurnal,  and  may  increase  until  urine  is  passed  every  ten  or  fifteen 
minutes  during  the  day,  and  every  half-hour  at  night.  There  is 
urgency,  and  sometimes  the  necessity  to  empty  the  bladder  is 
uncontrollable.  These  symptoms  are  usually  due  to  cystitis,  but 
may  occur  without  cystitis  and  with  a  clear  urine. 

Pain  may  be  due  to  cystitis,  to  obstruction  by  blood  clot,  or 
to  pressure  upon  nerves.  It  is  felt  along  the  urethra,  at  the  end 
of  the  penis,  in  the  suprapubic  region  and  groin,  in  the  perineum, 
anus,  and  down  the  thighs  or  along  the  sciatic  nerve.  Posterior 
renal  pain  may  be  unilaieral  or  bilateral,  and  is  due  to  obstruc- 
tion of  the  ureters  or  to  ascending  pyelonephritis.  Although  pain 
is  frequently  present  (63-4  per  cent,  of  cases)  and  may  be  the 
first  symptom  (8-8  per  cent.),  it  is  never  severe. 

The  urine  may  be  clear  in  the  intervals  of  hsematuria,  and 
contain  no  abnormal  elements.  Occasionally  a  persistent  excess 
of  epithehal  cells  from  the  bladder  may  be  found.  Portions  of 
growth  may  be  passed.  These  are  villi  from  the  surface  of  the 
growth,  and  their  structure  may  be  that  of  a  benign  papilloma. 
In  some  cases  the  irregularity  of  cell  growth  and  rapidity  of  pro- 
liferation suggest  malignancy. 

When  cystitis  is  present  the  urine  contains  pus,  mucus,  and 
blood.  The  urine  may  be  alkaline  and  stinking.  It  contains 
greyish  or  brownish  shreds,  which  may  be  blood  clot,  muco-pus, 
or  necrotic  portions  of  growth.  Masses  of  mucus  and  phosphatic 
or  more  sohd  concretions,  of  flat  or  hmpet-shell  shape,  form  on 
ulcerated  patches  and  are  discharged  with  the  urine.  Difficult 
micturition  (12  per  cent,  of  cases)  is  due  to  large  luxuriant  growths, 
or  to  smaller  growths  situated  near  the  urethral  orifice. 

Emaciation  is  present  in  advanced  cases.  It  is  not  a  reliable 
sign  of  malignancy,  for  it  may  be  caused  by  chronic  septic  pyelo- 
nephritis. 

Diagnosis. — Cases  of  mahgnant  growth  of  the  bladder  pre- 
sent two  chief  types,  a  cystitis  and  a  hsematuria  type. 

(1)  Cystitis  type  (40  per  cent.). — The  onset  may  be  sudden 
or  gradual,  and  occurs  without  the  passage  of  an  instrument. 

The  following  conditions  may  also  give  rise  to  spontaneous 
cystitis  in  a  man  of  50  years  or  over  : — 

(a)  Stone. — Here  the  onset  is  less  acute.  Pain  is  a  much  more 
prominent  symptom ;  it  is  sharp,  is  felt  at  the  end  of  the  penis 
and  at  the  close  of  micturition.  Hsematuria,  if  present,  is  terminal 
and  moderate,  and  the  blood  is  bright.  Frequent  micturition  only 
appears  during  the  day  ;  the  patient  sleeps  throughout  the  night 
without  waking.  All  the  symptoms  of  stone  are  greatly  increased 
by  movement  and  shaking. 


XXXV]    MALIGNANT  GROWTHS:    DIAGNOSIS      477 

(6)  Simple  enlargement  of  the  prostate. — The  onset  of  frequent 
micturition  is  gradual.  Nocturnal  frequency  is  pronounced  and 
commences  in  the  early  morning  after  a  rest  of  five  or  six  hours. 
Hsematuria  may  be  absent,  and  there  is  no  pain. 

(c)  Malignant  disease  of  the  prostate. — In  this  condition  there 
is  gradually  increasing  difhculty  in  micturition,  pain  is  a  prominent 
and  persistent  symptom  {72-5  per  cent,  of  cases),  hsematuria  is 
rare,  and  movement  has  no  influence  on  the  symptoms. 

(2)  HaBmaturia  type  (60  per  cent.). — These  cases  are  most 
likely  to  be  confused  with  simple  papilloma  or  with  tuberculous 
disease  of  the  bladder.  In  simple  papilloma  the  patient  is  usually 
younger  (under  45)  than  in  malignant  growth  (average,  57 
years).  The  hsematuria  is  sudden,  copious,  and  intermittent  in 
papilloma ;  it  is  insidious,  terminal,  persistent,  and  increasing 
in  malignant  growth.  The  hsematuria  of  papilloma  is  usually 
the  only  symptom,  while  frequent  micturition  and  other  symp- 
toms are  present  in  malignant  growth.  There  is  no  change  in 
symptoms  to  show  when  a  simple  papilloma  takes  on  malignant 
characters. 

Tuberculous  disease  usually  occurs  in  younger  patients.  It  can 
frec^uently  be  detected  in  the  genital  system  (epididymis,  prostate, 
seminal  vesicle),  or  there  are  tuberculous  lesions  elsewhere  in  the 
body.     The  tubercle  bacillus  is  found  in  the  urine. 

Examination. — Discrete,  shotty  enlargement  of  the  groin 
glands  is  occasionally  present  (12  per  cent,  of  cases).  Enlarged 
lymphatic  glands  can  be  detected  in  the  pelvis  on  rectal  examina- 
tion in  the  advanced  cases.  These  are  found  in  a  band  of  tissue 
at  the  upper  and  outer  angle  of  the  prostate  on  each  side,  and 
are  the  lowest  glands  of  the  lymphatic  chain. 

Palpation  of  the  base  of  the  bladder  from  the  rectum  or  vagina, 
and  especially  by  bimanual  examination,  may  detect  a  thickening 
of  the  wall. 

Cystoscopy. — Hsemorrhage  and  spasm  of  the  bladder  may 
render  cystoscopy  difficult. 

The  following  are  the  chief  types  of  malignant  growth  as  seen 
with  the  cystoscope  : — 

(a)  Villous  growth. — In  some  cases  there  is  nothing  to  dis- 
tinguish simple  from  malignant  papillomas.  Usually,  however, 
the  latter  are  sessile,  the  villi  are  stunted,  more  closely  packed, 
and  less  regular.  In  the  same  bladder  there  are  pedunculated 
and  sessile  growths.  Signs  of  infiltration  of  the  bladder  wall  may 
be  present.  The"  pedicle  is  thickened  and  more  fleshy,  the  sur- 
rounding mucous  membrane  is  ridged  and  puckered,  and  may  have 
an  infiltrated,   velvety  appearance.     Small  cedematous  tags  may 


478  THE   BLADDER  [chap. 

project  from  the  mucous  membrane,   and  separate  nodules  may 
be  seen. 

(6)  Nodular  sessile  or  pedunculated  growths. — These  vary 
in  size  from  a  large  pea  to  a  Tangerine  orange.  The  surface  is 
smooth,  and  may  be  firmly  or  coarsely  nodular,  opaque,  and  pink 
or  yellowish-pink  in  colour.  (Plate  35.)  The  surrounding  mucous 
membrane  may  show  signs  of  infiltration.  The  centre  of  the 
growth  is  sometimes  depressed  and  covered  with  a  gritty  mixture  of 
blood  clot  and  phosphates  (Plate  33),  or  may  be  necrotic  (Plate  35). 

(c)  Infiltrating  nodular  growths  and  depressed  ulcers. — 
The  appearances  have  already  been  described.  (Plate  34.)  The 
unaffected  portion  of  the  mucous  membrane  is  usually  the  seat 
of  subacute  or  chronic  cystitis.  Phosphatic  deposit  may  take 
place  on  the  growth. 

Course  and  complications. — The  average  duration  of  life 
after  the  first  appearance  of  symptoms  is  said  to  be  under  three 
years,  but  this  estimate  requires  qualification.  The  duration  of 
symptoms  in  papilloma  of  the  bladder  which  eventually  becomes, 
malignant  may  be  ten  or  fifteen  years.  Hard  infiltrating  growths, 
forming  a  depressed  ulcer  are  very  chronic,  although  the  duration 
is  shorter  than  that  of  papilloma.  Those  of  the  rapidly  growing 
papillomatous  variety  have  a  very  short  history,  death  taking 
place  frequently  under  a  year  and  always  under  two  years. 

Septic  complications  usually  result  from  the  passage  of  instru- 
ments, and  if  untreated  ascending  pyelonephritis  eventually  follows. 

Obstruction  of  the  ureters  is  a  frequent  complication  of  bladder 
growths.  If  one  ureter  is  involved  and  the  obstruction  is  gradual 
an  intermittent  hydronephrosis  results.  If  both  ureters  are 
occluded,  obstructive  anuria  supervenes.  Anuria  may  come  on 
suddenly  with  no  previous  symptoms,  or  after  symptoms  lasting 
a  few  hours.  Lymphatic  glands  are  involved  late,  and  metastatic 
deposits  in  the  lungs  and  liver  are  rare. 

Treatment. — The  treatment  is  operative  or  non-operative,  and 
the  operative  treatment  is  radical  or  palliative. 

Selection  of  cases  for  radical  operation. — Of  41  consecu- 
tive cases  under  my  observation,  only  15  (36-5  per  cent.)  were  fit 
for  the  operation  when  first  submitted  for  examination. 

Cases  suitable  for  a  radical  operation  must  fulfil  ^he  following 
conditions  :  (1)  The  growth  must  be  confined  to  the  bladder. 
(2)  The  patient  must  be  sufficiently  robust  to  undergo  a  severe 
operation. 

Evidence  of  disease  of  the  kidneys  or  of  renal  failure,  of  bron- 
chitis or  emphysema,  of  a  weak  or  failing  circulation,  must  be 
held  as  a  contra-indication  to  radical  operation. 


Fig.    1.      Nodular  malignant  growth    of   bladder. 
Fig.  2.'   Nodular  malignant  growth  of  bladder  with 

necrotic  surface. 
Fig.  3.— Small  nodular  malignant  growth  of  bladder. 

Recurrent     growth    after    removal.       {See 

Plate  33,  Fig.  4.) 

Plate  35.    (P.  478.) 


XXXV]   MALIGNANT  GROWTHS  :   OPERATIONS   479 

The  radical  operations  that  may  be  performed  in  suitable 
cases  are  (1)  resection  of  the  bladder  wall  and  (2)  cystectomy. 

Choice  of  radical  operation. — Wherever  possible,  resection  of 
the  bladder  wall  should  be  performed  in  preference  to  total  cystec- 
tomy, because  the  mortality  of  resection  varies  from  10  per  cent. 
(Thomson  Walker,  in  30  cases)  to  22  per,  cent.  (Enderlein  and 
Walbaum),  while  cystectomy  has  an  operation  mortality  of  from 
46-1  per  cent.  (Thomson  Walker,  collected  cases)  to  61-5  per 
cent.  (Goldenberg). 

The  cases  unsuitable  for  resection  are — 

(1)  Growths  covering  a  very  large  area  of  the  bladder  wall. 

(2)  Rapidly  growing  malignant  papillomas. 

(3)  Growths  involving  both  ureters,  or  the  trigone  or  urethra. 

(4)  Intractable  cystitis. 

None  of  these  is  a  contra-indication  to  cystectomy  provided 
the  conditions  previously  stated  are  fulfilled. 

Resection  of  the  bladder  wall. — Before  operation  the  posi- 
tion and  intravesical  extent  of  the  growth  are  ascertained  by 
cystoscopy.  At  the  operation  the  perivesical  extent  is  examined 
before  commencing  to  resect  the  bladder  wall.  Tumours  of  the 
lateral  wall  should  be  examined  from  the  outer  aspect  of  the 
bladder.  In  all  tumours  of  the  posterior  wall  the  peritoneum 
should  be  opened  and  the  peritoneal  surface  of  the  bladder  exam- 
ined. Tumours  at  the  base  are  examined  by  palpation  after 
cystotomy. 

A  vertical  median  suprapubic  incision  of  3|  in.  with  under- 
cutting of  the  rectus  muscle  on  the  side  of  the  growth  and  sub- 
sequent repair  suffices  for  the  majority  of  resections. 

In  stout  patients  a  transverse  curved  suprapubic  incision  may 
be  necessary. 

The  bladder  is  opened  and.  the  patient  placed  in  the  Trendelen- 
burg position,  illumination  being  obtained  from  a  powerful  head- 
lamp. In  tumours  of  the  anterior  wall  and  apex  of  the  bladder 
the  cystotomy  wound  should  be  placed  well  away  from  the  growth. 
An  area  of  bladder  wall  extending  for  at  least  an  inch  on  all  sides 
of  the  growth  is  removed,  and  the  edges  of  the  bladder  wall  are 
brought  together  by  catgut  stitches  round  a  rubber  tube,  which  is 
retained  for  four  days. 

In  tumours  situated  on  the  posterior  wall  (Figs.  142,  143,  144) 
cystotomy  is  first  performed,  and  then  the  peritoneal  cavity  is 
opened  and  the  peritoneal  aspect  examined.  An  area  of  peri- 
toneum is  marked  out  behind  the  growth  with  scissors,  and  the 
edges  are  stripped  ofl,  leaving  this  portion  adherent  to  the  bladder. 
The  peritoneal  cavity  is  now  closed.     The  cystotomy  wound  is 


480 


THE  BLADDER 


[chap. 


carried  back  and  surrounds  the  growth,  which  is  removed  with 
the  area  of  bladder  wall  and  peritoneum  on  which  it  is  set.  When 
the  growth  lies  in  the  neighbourhood  of  the  ureters  a  second  wound 
is  made  from  within  the  cavity  of  the  bladder.  A  catgut  suture 
is  passed  through  the  bladder  wall  IJ  in.  on  the  near  side  of  the 


Fig.  142. — Resection  of  posterior  wall  of  bladder  for 
malignant  growth. 

The  bladder  has  been  opened  by  suprapubic  cystotomy,  the  peritoneum  opened,  and  the 
intestines  packed  off,  exposing  the  puckered  peritoneal  surface  of  the  growth. 

growth.  By  traction  on  this  the  bladder  wall  is  steadied,  and 
with  a  long,  curved  pair  of  scissors  a  transverse  incision  is  made 
through  the  whole  thickness  of  the  bladder  wall  an  inch  from 
the  growth.     This  is  carried  round  the  growth,  leaving  an  inch 


xxxvj     MALIGNANT   GROWTHS:    RESECTION     481 

margin  of  healthy  bladder  wall.  As  the  section,  proceeds  catgut 
traction  sutures  are  inserted  every  half-inch  through  the  edge 
of  the  bladder  wound,  while  traction  on  the  growth  is  made  by 
a  stitch  passed  through  it.  Any  spouting  vessels  are  readily 
controlled. 


Fig.  143. — Resection  of  posterior  wall  of  bladder  for 
malignant  growth. 

The  portion  of  wall  bearing  the  growth  is  being  removed. 

If  the  ureteric  orifice  comes  within  the  area  of   the  resection 
the  lower  end  of  the  ureter  must  be  excised.     This  is  done  by 
continuing  the  wound  down  on  each  side  of  the  growth  and  raising 
2f 


482 


THE  BLADDER 


[CHAr. 


the  flap  thus  made.  The  ureter  is  exposed  on  the  extra  vesical 
aspect  of  this  flap,  secured  by  toothed  forceps,  and  cut  across. 
The  resection  having  been  finished,  the  cut  end  of  the  ureter  is 
raised  to  the  bladder  edge  of  the  growth  wound  at  the  nearest  point, 
and  a  catgut  stitch  passed  through  the  wall  of  the  ureter,  and 
then  through  the  bladder  wall,  and  tied.     Bleeding-points  having 


Fig.  144. — Resection  of  posterior  wdll  of  bladder  for 
malignant  growth. 

Bladder  surface  of  growth  shown  ;  resection  nearly  completed. 

been  ligatured,  the  growth  wound  is  stitched  with  catgut  sutures 
from  below  upwards,  using  the  traction  sutures  as  stitches.  When 
the  level  of  the  ureter  is  reached  a  second  stitch  is  passed  through 
its  wall  and  through  the  opposite  edge  of  the  growth  wound,  to 
which  it  is  already  fixed.  I  then  place  a  rubber  drainage  tube 
with  a  lateral  perforation  near  the  terminal  opening  alongside  the 


xxxvj  MALIGNANT  GROWTHS:  CYSTECTOMY  483 

ureter  in  the  extravesical  space,  and  this  passes  through  the  growth 
wound  across  the  bladder  and  out  of  the  cystotomy  wound.  It 
is  fixed  in  the  growth  wound  by  a  catgut  stitch.  The  remaining 
portion  of  the  growth  wound  is  now  closed,  the  bladder  mucous 
membrane  treated  with  nitrate  of  silver  as  in  papilloma  (p.  465), 
and  a  large  drain  placed  in  the  cystotomy  wound,  which  is  then 
closed  around  the  two  tubes.     The  abdominal  wall  is  now  repaired. 

The  catgut  stitch  holds  the  tube  alongside  the  ureter  for  seven 
days.  It  drains  the  extravesical  space  and  leaves  a  weak  spot 
in  the  bladder  wall  which  prevents  constriction  of  the  ureter. 
I  have  used  this  simple  method  of  ureteral  transplantation  success- 
fully in  ten  cases,  and  prefer  it  to  more  elaborate  methods.  In 
none  of  my  cases  has  there  been  any  postoperative  pyelonephritis 
after  resection  and  implantation  of  the  ureter. 

Cystectomy  :  treatment  of  the  ureters. — Some  method  of 
derivation  of  the  urine  must  be  adopted,  and  a  large  part  of  the 
high  operative  mortality  of  cystectomy  is  due  to  the  operation 
for  derivation  of  the  urine  being  performed  at  the  same  time  as 
the  removal  of  the  bladder.  "The  two  operations  should  be  per- 
formed at  an  interval  of  some  weeks. 

The  ureters  have  been  implanted  into  the  rectum,  large  in- 
testine, urethra,  vagina,  or  on  to  the  skin  in  the  loin  or  at  the 
suprapubic  wound,  or  bilateral  nephrostomy  may  be  performed. 

Maydl's  operation  of  transplanting  the  trigone  of  the  bladder 
^\'ith  the  ureters  cannot  be  done  in  growths  of  the  bladder. 

Implantation  of  the  ureters  into  the  rectum  is  seldom  suc- 
cessful, and  in  the  majority  of  cases  in  which  the  patient  has 
sur\aved  operation  a  fistula  has  formed  on  the  surface.  In  cases 
of  implantation  into  the  large  bowel  there  is  a  grave  danger  of 
ascending  septic  inflammation.  Implantation  of  ureters  into  the 
urethra  has  not  given  good  results.  Fixation  of  the  ureters  in  the 
suprapubic  wound  has  been  successful  in  several  cases.  After 
ureterostomy  there  is  considerable  danger  of  stenosis  and  of 
ascending  inflammation.  In  one  case  I  implanted  the  appendix 
into  the  dilated  right  ureter  {uretero-ap'pendicostomy,  see  p.  342). 

The  most  successful  operation  is  one  done  in  two  stages,  of 
which  the  first  stage  consists  in  derivation  of  the  urine  by  vaginal 
implantation  in  the  female,  and  nephrostomy  or  ureterostomy  in 
the  male  subject. 

Cystectomy  in  the  male  :  the  combined  perineo-abdo- 
minal  nnethod. — The  bladder  is  distended  with  fluid  and  the 
patient  placed  in  the  lithotomy  position.  A  curved  transverse 
prerectal  incision,  concave  forwards,  is  made,  and  the  posterior 
surface  of  the  prostate  and  seminal  vesicles  is  exposed. 


484  THE   BLADDER  [chap. 

The  patient  is  now  placed  horizontally,  and  then  raised  into 
the  Trendelenburg  position,  and  a  transverse  suprapubic  incision 
made  down  to  the  bladder.  The  peritoneum  is  then  stripped  by 
blunt  dissection  from  the  apex  and  posterior  wall  until  it  meets 
the  dissection  made  from  the  peritoneum.  The  vas  deferens  is 
separated,  the  seminal  vesicles  are  detached  and  pushed  back- 
wards, the  bladder  is  pulled  to  one  side,  and  the  ureter  and  large 
vessels  on  the  opposite  side  are  isolated  and  clamped ;  and  the 
same  is  done  on  the  other  side.  The  bladder  is  emptied  and  pulled 
up,  and  dissection  carried  transversely  between  the  front  of  the 
base  of  the  prostate  and  the  bladder,  and  the  prostatic  urethra  is 
clamped  and  cut  arcoss.  The  trigone  is  dissected  off  the  upper 
surface  of  the  prostate  and  the  bladder  removed.  The  lateral 
pedicles  are  now  ligatured.  The  peritoneum  may  be  opened, 
and,  instead  of  being  stripped  off,  the  adherent  portion  is  excised 
(intraperitoneal  method). 

Cystoprostatectomy. — The  preliminaries  are  the  same  as 
already  described,  but  the  prostate  is  completely  separated  from 
the  perineum,  the  membranous  urethra  is  cut  across,  and  the 
anterior  surface  of  the  prostate  separated  from  the  back  of  the 
pubic  bones.  The  patient  is  placed  in  the  Trendelenburg  position 
and  the  bladder  exposed,  the  peritoneum  stripped  off,  and  the 
lateral  pedicles  clamped  as  before.  The  bladder  is  drawn  upwards 
and  backwards,  the  pubo-vesical  ligaments  are  cut  across,  and 
the  bladder,  prostate,  and  seminal  vesicles  removed. 

Cystectomy  in  the  female  (Pawlik's  operation). — The  ureters 
are  exposed  from  the  vagina,  cut  across,  and  implanted  into  the 
vaginal  wall.  After  some  weeks  the  bladder  is  exposed  and  separ- 
ated from  the  peritoneum  by  a  vertical  suprapubic  incision.  A 
vaginal  incision  is  made  immediately  above  the  urethra,  and  the 
bladder  delivered  into  the  vagina  and  removed  after  cutting  across 
the  urethra.  The  urethra  is  then  implanted  into  the  vagina  and 
the  outlet  of  the  vagina  closed  by  a  second  operation  later,  so 
that  the  vagina  forms  a -reservoir  for  the  urine. 

Results.  Partial  resection. — In  96  collected  cases  of  partial 
resection  of  the  bladder  for  carcinoma  there  were  21  deaths  (21-8 
per  cent. — Watson).  The  author  has  performed  (March,  1911) 
resection  of  the  bladder  in  30  cases  of  malignant  growth,  with 
3  deaths  (10  per  cent.).  In  10  of  these  cases  one  ureter  was 
transplanted. 

Late  results. — Of  50  cases  of  partial  resection  collected  by 
Watson  there  was  recurrence  in  58  per  cent,  within  three  years, 
and  in  10  per  cent,  there  was  no  recurrence.  Kiimmel  reports  that 
of  47  cases  of  bladder  resection  for  malignant  growth  10  are  well 


XXXV]  CYSTECTOMY:    RESULTS  485 

al'ter  sixteen,  fifteen,  eij^lit,  uiid  six  uiid  a  half  years,  and   I    dicMJ 
of  recurrence  ten  years  after  the  operation. 

Ill  25  cases  of  resection  by  the  author  in  which  late  informa- 
tion was  obtained  there  were  3  deaths  from  ascending  pyelo- 
nephritis and  6  recurrences,  1  of  which  was  re-operated  (Plate  33, 
Fig.  4)  ;  in  17  cases  the  patients  were  alive  and  without  recurrence 
(1)  six  months  after  the  operation  in  6  cases,  (2)  twelve  months  in 
3  cases,  (3)  eighteen  months  in  6  cases,  (4)  two  years  in  1  case,  and 
(5)  four  and  a  half  years  in  1  case  (statistics  in  March,  1911). 

Cystectomy.— Oi  39  cases  collected  from  the  literature,  death 
occurred  after  the  operation  in  18,  a  mortality  of  46-1  per  cent. 
Only  10  cases  could  be  traced,  and  in  only  2  of  these  was  the 
period  after  the  operation  longer  than  fifteen  months.  One  was 
well  five  years  afterwards  (Hogge)  and  one  sixteen  years  (Pawlik). 

Later  statistics  give  an  even  higher  mortality.  Verhoogen  and 
de  Graeuwe  collected  59  cases  of  total  cystectomy,  with  an  opera- 
tive mortality  of  52-7  per  cent.  Of  the  27  cases  that  survived  the 
operation,  6  died  in  the  first  year,  7  died  before  the  third  year, 
and  only  2  survived  more  than  three  years.  In  12  cases  the  result 
was  unknown. 

Watson,  basing  his  statistics  on  collected  cases,  holds  that  the 
only  operation  that  offers  reasonable  hope  of  success  in  carcinoma 
of  the  bladder  is  total  extirpation  of  the  organ,  and  that  this 
operation  should  be  done  in  every  case  that  is  suitable  for  opera- 
tive interference.  He  also  holds  that  cystectomy  should  be  per- 
formed for  benign  growths  whenever  recurrence  takes  place,  "  or 
at  least  if  there  is  more  than  one  recurrence."  With  the  high 
operative  mortality  of  cystectomy  and  the  lack  of  encouraging 
statistics  of  the  after-results,  the  views  of  Watson  are  not  likely 
to  be  generally  accepted,  the  more  so  that  the  results  of  partial 
cystectomy  have  greatly  improved.  Cystectomy  must  at  the 
present  time  be  looked  upon  as  a  desperate  measure  which  holds 
out  little,  if  any,  prospect  of  cure. 

Palliative  treatment. — This  is  adopted  when  radical  operation 
is  contra-indicated,  and  consists  in  treating  symptoms  as  they  arise. 

Hcematuria. — In  severe  heematuria  the  patient  is  confined  to 
bed,  the  lower  end  of  the  bed  being  raised.  Opium  and  ergot  are 
given  hypodermically  and  calcium  lactate  by  the  mouth,  the 
latter  in  doses  of  10  gr.  every  four  hours  for  forty-eight  hours. 
The  bladder  should  be  washed  with  a  large  quantity  (several 
quarts)  of  hot  weak  silver  nitrate  solution  (1  in  10,000).  Con- 
tinuous irrigation  may  be  arranged  with  a  double-way  catheter. 
This  is  followed  by  the  instillation  of  a  small  quantity  of  adrenalin 
solution  (1  in  1,000). 


486  THE   BLADDER  [chap. 

If  the  bladder  becomes  distended  with  clots,  an  attempt  may 
■be  made  to  break  them  up  and  remove  them  by  means  of  an 
evacuating  cannula  and  bulb.  If  this  is  not  quickly  successful  the 
bladder  should  be  opened  suprapubically,  the  clots  cleared  out, 
and  a  large  drain  inserted. 

Partial  operations  involving  the  removal  of  the  salient  portion 
of  a  large  growth  by  the  suprapubic  route  and  subsequent  drainage 
are  sometimes  successful  in  relieving  severe  bleeding. 

Pain. — Pain  is  frequently  the  result  of  chronic  cystitis,  and 
in  such  cases  the  urine  is  usually  ammoniacal,  and  there  may  be 
phosphatic  deposits  on  the  bladder  wall.  Severe  pain  may,  how- 
ever, be  present  in  infiltrating  growths  with  little,  if  any,  cystitis. 
Treatment  consists  in  giving  suppositories  of  extract  of  bella- 
donna J  gr.  and  morphia  J  gr.,  to  which  cocaine  ^-1  gr.  may  be 
added. 

The  injection  of  tincture  of  opium  20  minims,  with  antipyrin 
30  gr.,  in  a  small  enema  of  hot  water,  frequently  gives  relief. 

Washing  the  bladder  with  silver  nitrate  solution  (1  in  10,000) 
may  be  beneficial,  and,  if  the  urine  is  alkaline  and  phosphatic 
material  is  being  deposited,  washing  with  a  very  weak  solution 
of  acetic  acid  (1  in  5,000)  and  the  administration  by  mouth  of 
sodium  acid  phosphate,  20  gr.  thrice  daily,  should  be  tried. 
Urinary  antiseptics  (urotropine,  etc.)  are  also  useful. 

Suprapubic  cystotomy  may  become  necessary,  and  the  cyst- 
itis should  be  treated  by  continuous  irrigation.  A  permanent 
drain  should  be  established,  an  apparatus  being  fitted^  and  the 
urine  drained  into  a  rubber  urinal  attached  to  the  thigh  (p.  549). 

Partial  operations  upon  the  growth  give  relief  from  pain  and 
from  serious  haemorrhage.  They  are  attended  with  some  danger 
of  septic  pyelonephritis  where  cystitis  is  present.  Nephrostomy, 
or  permanent  drainage  of  the  kidney  with  ligature  of  the  ureter 
just  below  the  renal  pelvis,  may  be  done.  Each  kidney  is  treated 
in  this  way,  and  an  apparatus  applied  to  the  loin  to  collect  the 
urine  (Watson).  Harrison  suggested  the  implantation  of  one 
ureter  on  the  skin  of  the  loin  and  the  removal  of  the  second 
kidney.  Fenwick  has  adopted  this  method,  applying  it  to  both 
sides  without  nephrectomy. 

2.    CONNECTIVE-TISSUE  NEW  GROWTHS 

FiBEOMA 

These  rare  tumours  are  small,  round,  pedunculated,  covered 
with  smooth  mucous  membrane,  and  of  a  yellowish-white  colour. 
They  consist   of  somewhat    loosely-set  fibrous  tissue  containing 


XXXV]    CONNECTIVE-TISSUE   NEW   GROWTHS    487 

few  blood-vc'ssi'ls.  Tlioy  arc  likely  to  be  confused  with  iiiuliguaiit 
growths.  Clado  collected  25  recorded  cases.  The  author  removed 
a  fibroma  the  size  of  a  hazel-nut  fioni  tlic  neighbourhood  of 
the  right  ureter  in  a  man  aged  30. 

Myoma,   Fibro-Myoma 

These  tumours,  of  which  about  20  examples  are  on  record, 
form  single,  very  rarely  multiple,  round  nodules,  which  project 
from  the  outer  surface  of  the  bladder  (extravesical),  or  into  the 
interior  of  the  viscus  (intravesical  or  submucous),  or  are  buried 
in  the  wall  (interstitial).  The  submucous  variety  are  peduncu- 
lated or  sessile,  firm,  round,  or  oval  tumours  foUnd  at  the  base 
of  the  bladder.  The  growth  consists  of  closely-set  non-striped 
muscle  fibres  in  whorls  or  irregularly  interlacing.  The  vascular 
supply  is  peripheral  and  abundant. 

Sarcomatous,  rarely  epitheliomatous,  degeneration  of  these 
tumours  has  been  described. 

Myxoma 

Pure  myxoma  of  the  bladder  is  rare,  and  is  found  almost 
exclusively  in  children.  The  tumours  are  situated  at  the  base 
of  the  bladder,  are  almost  always  multiple,  and  form  polypi  not 
unlike  those  of  the  nose,  but  of  firmer  consistence  and  darker- 
red  colour.  Growth  is  extremely  rapid,  and  recurrence  takes 
place  in  a  short  time  after  removal.  Microscopically  there  is  an 
abundant  granular  intercellular  substance,  in  which  are  round 
cells  and  a  few  branching  myxomatous  cells.  The  vessels  are 
large  and  numerous,  and  formed  of  a  single  layer  of  endothelium. 

Sarcoma 

Sarcoma  of  the  bladder  is  found  in  infancy  and  late  adult 
life,  and,  relatively  to  epithelial  tumours,  is  a  rare  growth.  Wilden 
states  that  in  50  cases  of  sarcoma  26  of  the  patients  were  over 
40,  and  14  were  under  10  years. 

Horder  found  4  cases  in  60  growths,  and  Targett  described 
4  in  36  specimens.  The  proportion  is  much  higher  in  children. 
Phocus  found  that  7  in  15  bladder  growths  in  children  were  sar- 
comas. Secondary  sarcoma  is  rare.  The  sarcoma  originates  in 
the  submucous  areolar  tissue,  less  frequently  from  the  extra- 
muscular  areolar  tissue  (Targett),  and  rarely  from  the  connective 
tissue  of  the  muscular  layer  (Bernstein). 

The  majority  of  these  tumours  arise  from  the  posterior  or 
lateral  walls  (57  per  cent. — Albarran),  and  the  trigone  is  seldom 
affected  unless  with  other  parts.     The  tumour  may  be  peduncu- 


488  THE  BLADDER  [chap. 

lated  or  sessile,  and  infiltrating.  Not  infrequently  the  bladder 
wall  is  widely  infiltrated,  and  projecting  into  the  interior  are 
numerous  polypoid  bodies.  The  cavity  of  the  bladder  may  be 
filled  with  masses  of  these  polypi.  The  surface  is  smooth  and  pink, 
or  deep  red,  and  of  the  consistence  of  hail.  The  ureteric  orifices 
may  be  surrounded  without  obliterating  the  lumen. 

The  urethra  is  sometimes  blocked  by  polypoid  bodies  which 
may  protrude  from  the  external  meatus  in  the  female.  The 
rectum,  intestine,  and  vagina  may  be  involved,  and  perforation 
of  the  bladder  wall  occasionally  occurs. 

The  spindle-celled,  round-celled,  and  rarely  the  melanotic 
varieties  of  sarcoma  are  found.  Myxoma  and  myxo-sarcoma  are 
also  described. 

Rhabdo-myoma  is  a  very  rare  tumour,  probably  arising  from  the 
striped  muscle  of  Henle  which  passes  up  the  anterior  surface  of 
the  prostate  as  far  as  the  bladder.  Chondro-sarcoma  is  another 
rare  form.  Angioma  has  been  described  by  Albarran  and  others  ; 
it  is  a  rare  form  of  tumour,  which  may  become  sarcomatous.  Two 
cases  of  chorion-epithelioma  have  been  described. 

3.    DERMOID  CYSTS 

Dermoid  cysts  are  occasionally  found  as  pedunculated  tumours 
the  size  of  a  pigeon's  egg,  or  buried  in  the  wall  of  the  bladder. 
Occasionally  a  perivesical  dermoid  cyst  ruptures  into  the  bladder. 
Clado  described  8  examples,  2  of  which  were  pedunculated  and 
6  sessile  tumours. 

LITERATURE 

Albarran,  Les  Tumeiirs  de  la  Vessie.     1891. 

Bangs,  Med.  Bee,  1911,  i.  359. 

Binney,  Boston  Med.  and  Surg.  Journ.,  1911,  p.  226. 

Block  and  Hall,  Amer.  Journ.  of  Med.  Sci.,  1905,  p.  654. 

Casper,  Bed.  Min.  Woch.,  1908,  Nr.  6  ;    Zeits.  f.    Urol.,  1909,  Supfl.,  441. 

Cassanello,    Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1908,  i.  641. 

Enderlein  und  Walbaum,  Festschr.  z.  60  Geburtstage,  0.  Ballingers.      Wiesbaden, 

1903. 
Gredenberg,  Beitr.  z.  Min.  Chir.,  1904. 
Harrington,  Ann.  Surg.,  Oct.,  1893. 

Kummel,  IP  Congres  de  1' Assoc.  Internat.  d'Urol.,  London,  1911. 
Liehtenstein,  Deuts.  med.  Woch.,  1898,  p.  709. 
Mayo,  Ann.  Surg.,  1908,  p.  105. 

Motz,  IIP  Sess.  de  1' Assoc.  Frang.  d'Urol.,  Paris,  1898,  p.  347. 
Paschkis,  Folia   Urol,  1908,  ii.  450. 
Pawlik,  Wien.  med.  Woch.,  Nov.  7,  1891. 
Rafin,  Proc.-verb.  Assoc.  Frang.  d'  Urol.,  1906,  p.  1. 
Rehn,  Centralbl.  f.  Chir.,  1904,  Suppl,  122. 

Rochet  et  Martel,"  Gaz.  Hebdom.  de  Med.  et  de  Chir.,  1898,  p.  337. 
Rovsing,  Arch.  f.  Idin.  Chir.,  1907,  p.  1407. 

Shattock,  Proc.  Roy.  Soc.  Med.,  Pathological  Section,  1909,  p.  31, 
Stoerk  und  Zuckerkandl,  Zeits.  f.  Urol.,  1907,  p.  1. 


XXXV]  VESICAL  NEW  GROWTHS  489 

LITERAT UUE  (conlinucd) 

Stump!,  Zciijlers  Bcitr.,   I'Jll,  p.   171. 

Treplin,  Dc'ut.'^.  mcd.    Woch.,   I'.HKi,  No.    1!). 

Verhoogen,  de  Graeuw^,  and  von  Rihmer,  XVI''  Congies  Internat.  dc  Med.,  Buda- 
pest,  liM)!),  p.  118. 

Walker,  Thomson,  "  Operations  on  the  Bladder,"  in  Burghard's  System  of  Opera- 
lire  Surgeri/,  190!),  vol.  iii.  ;  Lancet,  Nov.  12,  I'JlO  ;  II.  Congres  de  I'Assoc. 
Internat.  d'Urol.,  London,  1911. 

Watson,  Ann.  Surg.,  Dec,  1905  ;  Diseases  and  Surgery  of  the  Genito-  Urinary 
System,   1909. 

Weinrich,  Arch.  f.  hlin.  Chir.,  1906,  p.  887. 

Wendel,  Mitt.  d.  Grenzgeh.  d.  Med.  u.  d.  Chir.,  1900,  p.  15. 

Wilder,   Amer.  Joitrn.  Med.  Sci.,  1905,  p.  03. 


CHAPTER  XXXVI 
VESICAL  CALCULUS 

Etiology. — The  etiology  of  stone  formation  in  the  urinary  tract 
is  discussed  under  Renal  Calculus  (p.  249). 

Stone  in  the  bladder  is  less  frequent  in  children  than  in  adults, 
and  much  more  frequent  in  men — especially  old  men — than  in 
women. 

In  children  vesical  calculus  is  more  frequent  in  the  lower  class 
than  in  the  well-to-do.  When  stone  occurs  in  children  it  is  found 
in  the  bladder  in  the  great  majority  of  cases.  Bokay  found  that 
1,150  out  of  1,621  cases  of  urinary  calculus  in  children  were 
vesical. 

Calculi  are  primary  when  they  are  formed  in  an  aseptic  urine, 
and  secondary  when  they  result  from  changes  in  the  urine  caused 
by  bacteria.  The  nucleus  of  a  vesical  calculus  may  be  formed 
by  a  small  oxalate-of-lime  or  uric-acid  calculus  which  has  descended 
from  the  kidney,  or  the  stone  may  form  around  a  portion  of  blood 
clot  or  a  foreign  body  such  as  a  fragment  of  a  catheter,  a  pin,  a 
silk  ligature  from  a  previous  operation  on  the  bladder  (Figs.  152, 
153)  or  neighbouring  organs,  a  fragment  of  necrosed  bone,  etc. 

The  two  important  predisposing  factors  in  the  production  of 
secondary  calculi  are  bacterial  action  and  stagnation  of  urine. 
Of  these  bacterial  action  is  the  more  important. 

The  following  proof  of  the  presence  of  bacteria  in  the  interior 
of  calculi  is  of  interest.  In  a  woman  of  50  years  I  removed  a 
large  phosphatic  vesical  calculus  by  litholapaxy.  Previous  to  the 
operation  the  urine  had  been  aseptic.  The  centre  of  the  stone 
was  composed  of  soft,  greyish,  stinking  material,  and  cultures 
made  from  this  gave  an  abundant  growth  of  bacillus  coli.  The 
operation  was  followed  by  a  smart  attack  of  cystitis  due  to  the 
bacillus  coli  released  from  the  interior  of  the  stone  at  the  litho- 
lapaxy. The  patient  gave  a  history  of  removal  of  a  urethral 
caruncle,  followed  by  an  attack  of  cystitis,  three  years  before. 

Calculi  are  very  frequently  found  in  old  men  with  enlarged 
prostate  and  infected  urine,  and  they  may  form  in  the  stagnant 
urine  in  a  diverticulum  of  the  bladder. 

490 


CHAP.  XXXVl] 


VESICAL  CALCULUS 


491 


Fig.  145. — Radiogram  of  pure 
uric-acid  calculi  from  bladder, 
taken  after  removal. 

These  calculi  did  not  throw  a  shadow  when  in 
the  bladder. 


Chemicai  composition   and   physical   characters.     NCsiciil 
cuk'iili  ;uc  coiiqxj.scd  of  uric  acid,   pliosplialcs.   or  oxalulc  ol   lime, 
in  that  order  of  frequency,  and 
rarclv    of    cvstiii,  xantliin,   in- 
digo, or  calcium  carbonate. 

Uric-acid  calculi  (Figs.  145, 
146,  147)  may  be  pure  uric 
acid,  or  ammonium  or  sodium 
urate.  They  are  single  or  mul- 
tiple, varying  from  the  size  of 
a  split  pea  to  that  of  a  hen's 
egg.  They  are  rounded  or  oval 
and  may  be  flat ;  the  surface 
is  smooth,  or  very  finely  nod- 
ular, and  easily  polished.  They 
are  sandy  yellow  to  a  dark 
brown  in  colour,  and  on  sec- 
tion show  a  regular  concentric 
lamination.  They  are  hard, 
but  not  so  hard  as  oxalate- 
of-lime  calculi.  Calculi,  com- 
posed of  urates  are  similar 
in  contour,   but  lighter  in  colour  and  harder  in  consistence. 

Oxalate-of-lime  calculi  (Fig.  148)  are  round  and  usually  single. 
They  vary  from  a  pea  to  a  chestnut  in  size  and  have  a  dark- 
brown  colour.  The  sur- 
face is  covered  with 
closely-set  conical  bosses 
(mulberry  calculus),  or 
there  may  be  a  few  sharp 
projecting  spines  (star 
form).  The  calculi  are 
very  hard.  On  section 
they  are  composed  of 
closely  set,  irregularly 
disposed  laminae. 

Phospkatic  calculi 
(Figs.  149-53)  may  con- 
sist of  basic  calcium 
phosphate,  either  alone 
or  mixed  with  ammonio- 
magnesium  phosphate, 
and  in  addition  there 
may  be  ammonium  urate. 


Fig.   146. — Uric-acid   calculi  removed 
from  bladder. 


492 


THE   BLADDER 


[chap. 


Fig.  147. — Uric-acid  calculi  removed  from  bladder. 


Fig.  148. — Oxalate-of-lime  calculi  (mulberry  calculi) 
removed  from  bladder. 


XXXVlJ 


VESICAL  CALCULUS 


493 


Fig.  149. — Phosphatic  calculus 
of  bladder. 


These  stones  vary  greatly  in  consistence.     They  may  be  soft  and 
easily  crumble,  but  when  composed  of  crystalline  phosphates  they 
are   very   hard.     Sometimes    there  is  a  hard    outer    shell    and  a 
soft  interior.     On  section  they 
are  granular  and  rarely  show 
lamination. 

Cystin  calculi  are  oval, 
granular,  yellowish-brown,  and 
have  a  soapy  appearance. 
They  turn  a  greenish-yellow 
when  exposed  to  air.  XantJnn 
stones  are  smooth  and  yellow, 
and  indigo  are  ,  blue,  while 
calcium-carbonate  calculi  are 
greyish- white,  earthy-looking, 
hard  stones. 

Calculi  are  rarely  composed 
of  a  single  ingredient,  and  are 
frequently  named  uric-acid, 
oxalate  -  of  -  lime,  etc.,  only 
from  their  principal  ingredient. 

The  nucleus  in  primary  stones  is  most  frequently  uric  acid, 
less  often  oxalate  of  lime.     Around  the  nucleus  the  laminae  of 
oxalate   of  lime   or  of    uric   acid  are   disposed.     The  layers   may 
alternate.      The    sur- 
face      is      frequently 
covered  with  a  smooth 
layer    of    phosphates. 
Large  calculi   are 
usually      single,      but 
there     may     be     one 
large      calculus      and 
many  small  ones. 

Multiple  hard 
stones  are  rounded 
like  peas,  while  the 
softer  varieties  (phos- 
phates) are  angular 
and  faceted.  As  many 
as  400  or  500  may  be 
present.      Very   large 

stones  have  been  recorded:  Preston  found  one  weighing  51  oz., 
and  Earle  another  of  44  oz.,  at  an  autopsy;  and  Milton  re- 
moved one  of  34  oz.,  and  Clive  another  of  46  oz.,  by  operation. 


Fig.  150. — Phosphatic  calculus  removed 
from  bladder. 


494 


THE   BLADDER 


[chap. 


The  average  weight  is  200  or  300  gr.     Phosphatic  stones  develop 
rapidly,  and  a  large  stone  may  form  in  a  few  weeks.     Uric-acid 

calculi    form    less    ra- 
pidly,   and    oxalate-of- 
lime  very  slowly,   some 
years      being      usually 
taken    to    form    a    cal- 
culus of  moderate  size. 
Vesical    calculi    are 
either  movable  or  fixed. 
A    movable    stone    rolls 
about    in    the    bladder, 
and  its  position  varies 
according   to    the    atti- 
tude    of     the     patient. 
With    the    patient    re- 
cumbent   the    stone    usually   lies    on    the    posterior    wall,    just 
behind   the    base    of   the  trigone.     Large  calculi  in  an  inflamed, 
sensitive  bladder  are  occasionally  found  at  the  apex  spasmodically 


Fig.  151. — Phosphatic  calculi  removed 
from  bladder. 


Fig.  152. — Phosphatic  calculi  formed  around  silk  sutures 
used  in  removal  of  bladder  growth. 

grasped  in  a  partial  contraction  of  the  bladder.  The  lower  part 
of  the  bladder  is  not  contracted,  and  contains  fluid.  Freely 
movable  stones  take  a.  rounded  or  flat  oval  form. 


xxxvij  VESICAL   CALCULUS  495 

Ultzmann  holds  that  the  contour  of  the  stone  depends  upon 
the  crystals  of  which  it  is  composed.  Urates,  uric  acid,  earthy 
phosphates,  and  cystin  belong  to  the  rhomboidal  crystalline  form, 
and  produce  flat  ovoid  stones  varying  in  the  three  axes.  Calcium 
oxalate  belongs  to  the  quadrate  crystal  form,  and  produces  a 
rounded  calculus.  Secondary  deposits  change  the  contour  of  the 
stone :  a  rounded  oxalate  stone  covered  with  uric  acid  becomes 
egg-shaped,  while  an  ovoid  uric-acid  imcleus  becomes  rounded 
when  oxalate  of  lime  is  deposited  upon  it. 

When  a  number  of  calculi   are  closely  packed  together  they 


Fig.  153. — Phosphatic  calculi  formed  around  silk  sutures 
used  to  close  a  cystotomy  wound. 

take    a    polygonal    form    with    facet-like    surfaces ;    when    freely 
movable  they  take  a  rounded  form. 

A  fjxed  stone  is  found  in  a  diverticulum  or  saccule,  or  project- 
ing into  the  bladder  from  the  lower  end  of  the  ureter  or  from  the 
urethra,  or  in  a  diverticulum  at  the  apex  of  the  bladder,  the 
patent  lower  end  of  the  urachus  (Dykes).  When  a  stone  lies 
within  the  cavity  of  a  diverticulum  it  is  rounded  or  oval,  and 
it  may  be  movable  within  the  diverticulum  or  fixed.  The  opening 
of  the  diverticulum  may  be  so  small  that  the  stone  cannot  be 
seen  from  the  bladder.  Stones  which  project  from  the  prostatic 
urethra  into  the  bladder  increase  rapidly  in  the  shape  of  a 
mushroom  or  umbrella. 


496  THE  BLADDER  [chap. 

Spasmodic  contraction  of  the  bladder  wall  around  a  large  stone 
may  fix  the  stone  in  the  upper  or,  in  children,  in  the  lower  part 
of  the  bladder.  Such  contractions  may  give  the  bladder  an  hour- 
glass form,  one  part  of  the  bladder  being  distended  with  fluid; 
while  the  other  is  firmly  contracted  round  the  stone. 

In  enlargement  of  the  prostate,  stones  may  be  wedged  in  the 
deep  pocket  behind  the  intravesical  projection  so  that  they 
become  fixed. 

Pathology. — Cystitis  may  precede  the  formation  of  stone, 
or  may  result  from  its  presence.  The  inflammation  may  be  con- 
fined to  the  base  of  the  bladder,  or  it  may  be  universal.  The  bed 
on  which  the  stone  lies  frequently  consists  of  a  thick,  shaggy, 
greyish-white  membrane  formed  of  thickened  and  necrosed  epi- 
thelium with  muco-pus. 

Papilloma  or  malignant  growth  is  present  in  rare  cases.  Chronic 
pyelonephritis  is  found  in  cases  of  long-standing  calculous  cystitis, 
and  is  the  cause  of  death  in  most  fatal  cases  of  stone. 

Spontaneous  fragmentation  of  a  vesical  calculus  has  been 
known  to  occur,  and  it  has  been  most  frequently  observed  in 
uric-acid  calculi.  Watson,  Dabout  d'Estrees,  Kasarnowsky,  and 
others  have  described  such  cases.  The  phenomenon  is  ascribed 
either  to  mechanical  or  to  chemical  action.  Ord  believed  that  it 
was  due  to  the  colloid  cement  substance  of  the  calculus  becoming 
saturated  with  urine  of  low  specific  gravity,  such  as  is  produced 
by  diuretic  waters.  Leroy  d'Etoilles  regarded  a  drying  and 
shrinking  of  the  calculus  as  an  essential  factor.  Heller  explained 
the  fracture  by  supposing  that  tension  was  produced  within  the 
calculus  by  decomposition  of  ammonium  urate  lying  between 
layers  of  uric  acid.  Civiale,  and  later  Kapsammer,  held  the  view 
that  the  mechanical  action  of  bladder  contractions  produced  the 
fragmentation.  If  the  mechanical  view  were  correct,  fracture 
would  be  expected  to  occur  more  frequently  in  multiple  calculi 
and  when  the  bladder  was  spasmodically  contracted ;  but  this 
is  not  the  rule,  and  Zuckerkandl  points  out  that  fragmentation 
may  occur  in  an  atonic  bladder.  At  the  present  time  the  factors 
which  govern  this  rare  phenomenon  are  unknown. 

Symptoms. — A  stone  which  descends  from  the  kidney  may 
give  rise  to  a  varying  series  of  symptoms.  There  are  one  or  several 
attacks  of  renal  colic,  which  may  be  followed  at  once  by  symp- 
toms of  bladder  irritation  and  the  immediate  discharge  of  the 
calculus  with  the  urine.  Frequently,  however,  a  period  of  relief 
from  symptoms  follows  the  discharge  of  the  calculus  into  the 
bladder,  and  this  may  last  for  some  days,  weeks,  or  even  months. 
Symptoms  commence  again  when  the  calculus  is  swept  into  the 


xxxvij     VESICAI.   CALCULUS:    SYMPTOMS  W7 

urethra  to  be  impacted  in  that  tube  or  passed  through  it,  or  when 
irritation  of  the  bladder  is  produced  by  the  continual  movement 
of  the  stone,  or  finally  when  infection  takes  place. 

Legueu  states  that  calculi  which  form  in  infancy  may  remain 
quiescent  for  ten  or  even  twenty  years. 

Fixed  calculi  give  rise  to  no  symptoms  directly  referable  to 
stone,  and  very  large  calculi  are  frequently  "  latent." 

FrequeM  micturition. — This  is  the  most  common  and  the  earliest 
symptom.  The  increased  frequency  commences  gradually  and 
is  progressive.  There  is  urgency  to  pass  water,  and  the  desire, 
once  felt,  becomes  an  imperative  necessity.  After  passing  water 
there  is  discomfort,  and  a  feeling  that  the  bladder  has  not  been 
emptied.  These  symptoms  are  aggravated,  and  may  only  be  pre- 
sent, when  the  patient  moves  about  or  is  subjected  to  the  jarring 
of  horse-riding,  bicycling,  or  travelling  in  a  railway  carriage  or  a 
bus.  In  the  recumbent  position  the  stone  falls  away  from  the 
sensitive  neck  of  the  bladder,  and  the  desire  to  pass  water  is  no 
longer  felt.     The  patient  sleeps  peacefully  throughout  the  night. 

Pain. — Pain  is  a  prominent  symptom.  It  is  felt  at  the  neck 
of  the  bladder  and  at  the  end  of  the  penis,  either  at  the  external 
meatus,  at  the  base  of  the  glans  on  the  dorsum,  or  most  frequently 
beneath  the  fraenum.  The  pain  occurs  at  the  end  of  micturition, 
is  sharp  and  "  cutting,"  and  is  increased  by  movement  and  jarring. 

HcBmaturia. — Terminal  haematuria  is  a  frequent  symptom.  A 
few  drops  of  blood  are  squeezed  out  at  the  end  of  micturition. 
The  blood  is  bright,  and  the  haemorrhage  not  severe.  Movement 
and  rest  influence  this  in  the  same  manner  as  the  other  symptoms. 

An  intermittent  stream  may  be  observed.  Arrest  in  the  middle 
of  the  act,  accompanied  by  severe  pain,  is  due  to  impaction  of  the 
stone  at  the  internal  meatus.  The  arrest  may  be  momentary,  or 
it  may  be  impossible  to  start  the  flow  for  some  minutes,  or  even  ■ 
a  quarter  of  an  hour.  If  the  patient  lies  down  the  stone  rolls 
away  from  the  internal  meatus  and  water  can  be  passed  freely. 

Continued  retention  of  urine,  necessitating  the  use  of  the 
catheter,  is  rare  when  the  stone  is  still  in  the  bladder.  It  may 
occur  when  the  stone  has  become  impacted  in  the  prostatic  urethra, 
and  is  usually  accompanied  by  severe  pain  and  strangury. 

The  urine  contains  crystals  of  oxalate  of  lime,  uric  acid,  or 
phosphates.  The  urinary  deposit  for  the  time  indicates  the 
composition  of  the  surface  layer  of  the  calculus. 

Microscopic  quantities  of  blood  and  an  excess  of  leucocytes 
and  epithelial  cells  are  usually  fomid  in  the  urine. 

In  children,  screaming  on  micturition  and  retention   of  urine 
are  not  infrequent.     In   other  cases  there  is  incontinence  from 
2g 


498  THE   BLADDER  [chap. 

frequent  involuntary  expulsion  of  the  urine  caused  by  the  irrita- 
tion of  a  stone  forced  down  into  the  neck  of  the  bladder.  In  small 
boys  "  milking  "  of  the  penis  is  an  attempt  to  ease  the  pain,  and 
leads  to  an  enlarged,  turgid,  semi-erect  condition  of  the  penis 
which  is  very  characteristic. 

When  cystitis  complicates  stone  the  symptoms  are  modified. 
The  frequency  is  increased,  and  is  continued  at  night  as  well  as 
during  the  day ;  the  pain  grows  more  intense,  and  pus  and 
mucus  appear  in  the  urine,  which  often  becomes  alkaline  and 
stinking. 

In  old-standing  cases  symptoms  of  ascending  pyolonephritis 
appear,  and  the  patient  rapidly  loses  weight,  and  eventually  dies 
of  "  urinary  septicaemia  "  {see  p.  133).  Pericystitis  with  perfora- 
tion into  the  rectum  or  vagina  is  a  rare  complication. 

Diagnosis. — Pain  similar  to  that  of  calculus  may  occur  in  other 
diseases  of  the  bladder,  such  as  cystitis  or  malignant  growth ;  but 
the  pain  in  calculus  is  a  prominent  symptom,  it  is  sharp,  occurs 
at  the  end  of  micturition,  and  is  markedly  affected  by  movement 
and  rest.  The  heematuria  and  frequent  micturition  are  also 
increased  by  movement.  The  gradual  onset  of  frequent  micturi- 
tion, diurnal  in  character,  is  very  characteristic  of  stone.  When 
cystitis  is  present  a  calculus  may  be  suspected  if  the  pain  is 
unusually  severe  and  all  the  symptoms  are  markedly  increased 
by  movement  and  jarring.  The  previous  passage  of  a  calculus  is 
an  important  aid  to  diagnosis.  Tuberculous  cystitis  in  children 
or  adults  may  give  rise  to  difficulty  in  diagnosis.  Pain  is  sel- 
dom so  acute,  and  the  frequency  is  continued  at  night  as  well 
as  during  the  day,  while  movement  has  little  effect  upon  the 
symptoms. 

Malignant  growth  of  the  bladder  may  give  rise  to  symptoms 
closely  resembling  stone.  Here  the  pain  is  constant,  is  not  so 
sharp,  and  movement  has  no  effect  upon  the  symptoms. 

Calculus  in  combination  with  enlarged  prostate  may  be 
attended  by  no  distinctive  symptoms,  and  the  stone  is  usually 
found  during  an  examination  of  the  bladder,  or  at  the  operation 
for  enlarged  prostate. 

Has  a  stone  which  is  known  to  have  been  descending  the 
ureter  been  discharged  into  the  bladder,  or  is  it  still  in  the  lower 
end  of  the  ureter  ?  The  symptoms  of  stone  in  both  these  situa- 
tions may  be  similar,  but  the  effect  of  movement  is  seldom  so 
marked  in  ureteral  calculus,  and  symptoms  of  irritation  of  the 
genital  system,  such  as  erections  and  emissions,  are  frequently 
observed  when  the  calculus  is  in  the  lower  ureter.  Usually;  when 
the  calculus  passes  into  the  bladder  the  symptoms  suddenly  cease, 


XXXVI I      VESICAL  CALCULUS:   SOUNDING  499 

and  they  may  not  recur  until  the  calculus  is  passed  through  the 
urethra  or  impacted  in  that  tube. 

The  only  certain  method  of  distinguishing  between  stone  in 
the  lower  ureter  and  stone  in  the  bladder  is  by  the  use  of  the 
cystoscope. 

Examination. — As  a  rule,  it  is  not  possible  to  detect  a  stone 
of  moderate  size  by  rectal  or  vaginal  examination.  Even  large 
stones  may  not  be  palpable  from  the  rectum,  on  account  of  the 
thickened  bladder  wall.  They  may,  however,  be  felt  on  bimanual 
examination. 

Sounding:  the  bladder. — Before  sounding  a  patient  it  is 
necessary  to  exclude  urinary  tuberculosis  by  bacteriological  exam- 
ination of  the  urine  and  other  means.  If  tuberculosis  is  present 
the  bladder  should  not  be  sounded. 

The  most  stringent  precautions  in  regard  to  asepsis  must  be 
exercised  in  this  examination.  The  instruments  are  boiled,  the 
hands  rendered  surgically  clean,  and  the  area  of  operation  is  sur- 
rounded by  clean  towels.  The  penis  is  washed  with  antiseptics. 
In  children  a  general  ansesthetic  is  usually  necessary,  but  in  adults 
none  is  required. 

The  patient  lies  on. a  high  couch,  and  the  surgeon  stands  on 
his  right.  Four  or  six  ounces  of  fluid  are  introduced  into  the 
bladder  through  a  catheter,  which  is  then  removed.  The  sound 
is  introduced  and  pushed  on  until  it  is  arrested  at  the  apex  of 
the  bladder  in  the  middle  line.  The  beak  is  turned  first  to  one 
side  and  then  to  the  other,  and  the  instrument  drawn  slowly  out, 
tapping  the  bladder  on  each  side  of  the  middle  line  by  turning 
the  beak  from  side  to  side,  until  it  is  arrested  at  the  internal 
meatus.  Then  the  postprostatic  area  is  examined  by  raising  the 
handle  of  the  sound  until  it  is  vertical,  and  finally  by  turning 
the  beak  down  behind  the  prostate  if  it  is  enlarged.  As  the  in- 
strument is  withdrawn  the  surgeon  should  pay  particular  attention 
to  grating  or  impact  with  a  stone  in  the  prostatic  urethra.  When 
the  beak  of  a  sound  comes  in  contact  with  a  stone  in  the  bladder 
a  sharp  metallic  click  is  heard,  and  the  impact  can  be  felt  with 
the  thumb  and  forefinger  lightly  holding  the  instrument.  An 
idea  of  the  size  of  the  stone  may  be  gained  by  noting  the  distance 
to  which  the  sound  is  withdrawn  while  the  beak  still  rings  upon 
the  stone.  Multiple  calculi  may  be  detected  by  the  impact  taking 
place  when  the  beak  is  turned  first  on  one  side  and  then  on  the 
other. 

In  children  the  stone  lies  at  the  neck  of  the  bladder,  and  the 
sound  at  once  impinges  upon  it ;  in  adults  in  the  dorsal  decu- 
bitus the  stone  falls  into  the  post-trigonal  area,  and  in  old  men 


500  THE   BLADDER  [chap. 

the  stones  are  usually  found  behind  an  intravesical  projection  of 
the  prostate  (postprostatic  pouch).  A  calculus  may  not  be  felt 
with  the  sound  when  it  is  embedded  in  the  folds  of  a  partially 
distended  bladder,  when  it  is  grasped  by  a  spasm  of  an  irritable 
bladder,  when  it  lies  behind  an  enlarged  prostate  or  in  a  diver- 
ticulum, or  when  it  is  covered  by  a  thick  layer  of  mucus  and  pus. 
The  ridges  of  a  trabeculated  bladder,  or  phosphatic  deposit  on 
the  mucous  membrane  in  chronic  cystitis  or  on  a  new  growth, 
may  give  rise  to  difficulties  in  diagnosis  with  the  sound ;  and  the 
operator  should  be  careful  that  the  handle  of  the  instrument 
does  not  come  in  contact  with  hard  bodies  such  as  a  ring  or  a 
button. 

When  a  small  stone  cannot  be  felt  with  the  sound  the  follow- 
ing method  may  detect  it  (Freyer)  :  The  cannula  of  a  litholapaxy 
evacuator  is  passed,  a  few  ounces  of  fluid  are  introduced,  and  the 
evacuating  bulb  is  applied.  At  diastole  of  the  bulb  the  small 
calculus  is  sucked  against  the  eye  of  the  metal  cannula  with  an 
easily  detected  click. 

Cystoscopy  (Plate  36). — This  is  the  most  certain  method  of 
detecting  a  calculus.  Movable  calculi  are  found  just  behind  the  inter- 
ureteric  bar.  Large  calculi  in  a  contracted  bladder  may  be  difficult 
to  view,  as  they  are  pushed  aside  by  the  beak  of  the  cystoscope. 
Calculi  lying  behind  the  prostate  or  in  a  sacculus  or  at  the  mouth 
of  the  ureter  are  readily  seen  with  the  cystoscope,  while  they  may 
escape  detection  with  the  sound.  When  a  diverticulum  has  a 
small  opening  it  may  contain  a  large  calculus  which  cannot  be 
seen  with  the  cystoscope.  The  number  of  calculi  present  in  the 
bladder  and  their  position  and  appearance  are  readily  ascertained. 
I  have  seen  a  small  spherical  growth  of  the  bladder  entirely  covered 
with  phosphates,  which  exactly  resembled  a  phosphatic  stone, 
except  that  the  position  was  constant  to  the  outside  of  the  right 
ureter  in  different  positions  of  the  patient.  In  another  case  where 
a  stone  shadow  was  shown  by  radiography  the  cystoscope  revealed 
in  addition  a  large  papillomatous  growth,  and  litholapaxy  was 
abandoned  for  suprapubic  cystotomy. 

Radiography. — A  shadow  in  the  vesical  area  {see  p.  360)  may 
be  cast  by  a  stone  in  the  bladder,  in  the  lower  end  of  the  ureter, 
or  in  a  diverticulum.  A  vesical  stone  shadow  is  usually  in  the 
middle  line,  and  it  can  be  made  to  change  its  position  by  move- 
ments of  the  patient.  The  shadow  thrown  by  a  calculus  in  a 
diverticulum  is  more  likely  to  be  to  one  side  of  the  middle  line, 
and  this  position  may  also  be  taken  by  a  shadow  thrown  by  a 
stone  in  the  bladder  pushed  aside  by  a  growth. 

Treatment. — There  is  no  means  by  which  a  stone  in  the 


Fig.   1.-  Large    phosphatic  calculus  with  cystitis. 

Fig.  2.  —  Uric-acid   calculi  covered   with   thin  layer 
of  phosphates. 

Fig.  3.  —  Oxalate-of-lime  calculi  in  bladder. 
Plate  36.    (P.  500.) 


XXXVI]    VESICAL   CALCULUS:   TREATMENT         501 

bladder  can  be  dissolved,  whether  by  medicines,  or  waters  adminis- 
tered by  mouth,  or  washes  used  k)cally. 

When  a  stone  has  been  passed  in  the  urine  a  thorough  examin- 
ation witli  tlie  cystoscope  or  X-rays  sliouhl  t'oUow  to  make  certain 
that  no  other  calcuh  are  present  in  the  bhidder,  ureters,  or  kidney. 
When  a  stone  has  been  passed  down  the  ureter  into  the  bladder 
and  lias  not  inmiediately  been  discharged  through  the  urethra, 
its  removal  from  the  bladder  should  be  proceeded  with  as  soon 
as  possible ;  for,  although  there  is  a  fair  probability  of  the  stone 
passing  through  the  urethra,  there  is  also  considerable  danger  that 
it  may  become  impacted  in  that  tube — an  accident  that  may  give 
rise  to  much  pain  and  considerable  difficulty  in  attempting  to 
push  the  calculus  back  into  the  bladder,  and  may  necessitate  a 
perineal  operation  for  its  relief. 

A  small  calculus  may  sometimes  be  removed  by  means  of  the 
cannula  and  aspirator  (Fig.  154)  used  in  litholapaxy.     This  should 


Evacuating  cannula  and  stylet. 


be  performed  under  the  same  aseptic  conditions  that  are  neces- 
sary in  a  crushing  or  cutting  operation.  A  general  anaesthetic  is 
preferable,  although  it  may  be  dispensed  with,  or  local  anaesthesia 
used  when  the  operator  is  skilful  and  the  patient  placid. 

The  largest  cannula  that  the  urethra  will  take  is  passed  and 
the  bladder  emptied.  Four  or  five  ounces  of  warm  boric  lotion 
are  introduced  by  means  of  a  bladder  syringe,  and  the  aspirating 
bulb,  filled  with  boric  solution,  is  applied  to  the  cannula.  The 
bulb  is  raised  so  that  the  beak  of  the  cannula  lies  at  the  lowest 
part  of  the  bladder,  and  is  compressed  and  relaxed.  At  diastole 
the  calculus  is  felt  to  click  at  the  eye  of  the  cannula,  and  it  drops 
into  the  glass  bulb.  The  aspirating  bulb  is  removed,  the  bladder 
emptied  and  then  washed  with  a  few  syringefuls  of  silver  nitrate 
solution  (1  in  10,000). 

This  method  is  only  applicable  to  small  stones  which  have 
recently  descended  from  the  kidney,  or  to  small  fragments  of 
phosphatic  grit  found  in  the  course  of  chronic  cystitis.  It  should 
not  be  attempted-  unless  the  surgeon  is  skilled  in  litholapaxy 
and  is  prepared  at  once  to  proceed  to  this  operation  if  suction 
fails. 


502 


THE   BLADDER 


[chap. 


The  operations  which  are  performed  for  stone  in  the  bladder 
are  of  two  kinds — (1)  crushing  (Utholapaxy  or  hthotrity),  and 
(2)  cutting  (lithotomy). 

1.  Litholapaxy  or  Hthotrity. — The  modern  operation  of 
litholapaxy,  which  consists  in  crushing  a  stone  and  removing  the 
fragments  at  one  sitting,  was  introduced  by  Bigelow,  of  Boston,  in 


Scales 


Fig.  155. — Thompson's  lithotritCi 

1878,  and  became  firmly  established  as  the  operation  of  choice 
for  vesical  calculus  through  the  work  of  Freyer,  Keegan.  and  other 
officers  of  the  Indian  Medical  Service.  Previous  to  this  date  the 
operation  consisted  in  crushing  the  stone  and  allowing  the 
fragments  to  be  swept  out  by  the  urine. 

The  instruments  necessary  for  litholapaxy  are  a  lithotrite  and 
evacuating  apparatus.  Lithotrites  of  shghtly  varying  construc- 
tion have  been  introduced  by 
Weir,  Bigelow,  Guyon,  Thomp- 
son (Fig.  155),  Freyer,  and 
others. 

The  lithotrite  consists  of 
two  blades,  one  of  which,  the 
male  blade,  glides  in  a  sunken 
groove  in  the  other.  The  beak 
is  set  at  an  angle,  and  the 
female  portion  of  it  is  concave 
and  fenestrated,  while  the  male 
is  convex  and  toothed.  The 
handle,  by  which  the  instru- 
ment is  held  in  the  left  hand 
of  the  operator  during  the 
crushing,  is  attached  to  the 
female  blade,  and  the  screw, 
which  is  manipulated  with  the 
right  hand,  passes  through  this 
and  belongs  to  the  male  blade.  By  a  mechanical  device,  controlled 
either  by  a  movable  button  on  the  handle  (Thompson)  or  a  screw 
cap  attached  to  the  male  blade  (Bigelow),  the  two  blades  can  be 
locked,  and  can  then  only  be  approximated  by  means  of  a  power- 
ful screw  worked  on  the  male  blade  by  a  wheel  (Thompson),  or  by 


Fig.  156. — Freyer's  aspirator. 


xxxvi] 


LITHOLAPAXY 


)03 


a  conical  serrated  handle  (Bigelow).  The  cannula  consists  of  a 
straight  metal  tube  with  a  short  beak  and  a  large  eye,  the  proximal 
end  of  which  fits  into  the  tube  of  the  aspirator.  The  size  of  the 
cannula)  varies  from  12  to  18  English  scale.  There  have  been  many 
modifications  of  Bigelow's  aspirator.  That  of  Freyer  (Fig.  156) 
is  the  simplest  and  best.  It  consists  of  a  bulb  of  thick  rubber, 
on  the  lower  aspect  of  which  is  an  opening  to  which  a  glass  bulb 
is  attached ;  close  to  this,  and  steadied  by  a  metal  bridge,  is  a 
metal  tap  and  stopcock.     This  fits  on  to  the  proximal  end  of  the 


Fig.  157. — Litholapaxy :    Grasping  the  stone  and  locking 
the  blades. 

Note  the  angle  of  the  instrument ;  the  blades  are  in  the  most  dependent  part  of  the  bladder. 

The  stone  is  grasped  between  the  blades,  and  the  thumb  of  the  operator's  left  hand  is  pushing 

up  the  locking  button. 

cannula.  Pardoe  has  modified  this  by  replacing  the  pressure 
band  of  twisted  wire  which  holds  the  rubber  bulb  and  glass  bulb 
together  by  a  metal  band  with  a  spring  clip. 

The  operation  of  litholapaxy  (Figs.  157,  158,  159,  and  Plate 
37)  is  carried  out  as  follows  :  The  patient  is  prepared  by  the 
administration  for  some  days  of  10  gr.  of  urotropine  thrice  daily, 
the  bowels  are  emptied  by  an  aperient,  and  the  rectum  cleared 
before  the  operation  by  an  enema.  A  general  anaesthetic  is  admin- 
istered. The  pelvis  is  slightly  raised  on  a  low,  flat  cushion.  The 
bladder  is  thoroughly  washed  with  warm  boric  solution  and  the 
catheter  withdrawn,  leaving:  4  or  5  oz.  of  the  solution  in  the  bladder. 


504 


THE  BLADDER 


[chap. 


If  the  meatus  is  narrow  it  is  slit  downwards.  The  surgeon  stands 
on  the  right  side  of  the  patient,  and  the  lithotrite,  with  the  male 
blade  pushed  home  and  well  lubricated,  is  passed  along  the  urethra 
until  the  beak  is  inside  the  bladder.  The  handle  is  then  raised 
so  that  the  beak  descends  to  the  lowest  part  of  the  bladder  (the 
post-trigonal  area  in  this  position),  and  the  blades  are  separated. 
The  stone,  which  is  lying  at  the  lowest  part  of  the  bladder,  rolls 
in  between  the  blades,  and  is  caught  when  the  male  blade  descends 
upon  it.     Should  the  stone  not  be  grasped  by  the  manoeuvre  the 


Fig.  158. — Litholapaxy :   Crushing  the  stone. 

The  stone  having  been  caught  between  the  blades  of  the  lithotrite  and  the  blades  locked,  the 
handle  is  firmly  grasped  in  the  left  hand  ;  the  right  hand  is  turning  the  screw. 

blades  are  separated  and  the  instrument  turned  to  the  right  or 
left,  or  pushed  well  up  into  the  apex  of  the  bladder,  or  finally 
turned  downwards  behind  the  prostate  if  this  is  enlarged.  The 
blades  are  now  locked,  the  beak  raised  slightly  from  the  bladder 
wall,  and  the  screw  rapidly  turned,  the  female  blade  being  kept 
absolutely  steady  by  holding  the  handle  rigid  with  the  left  hand. 
When  the  blades  have  closed  the  screw  is  thrown  out  of  gear  and 
the  blades  are  separated,  a  fragment  seized  as  before  and  crushed. 
The  crushing  should  proceed  with  the  lithotrite  in  this  position 
until  no  more  fragments  are  grasped,  then  it  may  be  turned  on  one 
side,  opened,  and  a  fragment  (if  any  are  left)  grasped,  the  beak 
again  turned  into  the  erect  mid-line  position,  and  the  fragment 


Fi^.     1. — Shadow    of    calculus 
(P.  5C4.) 


in    grasp    of    lithotrite. 


Fig.  2. — Shadow  of  evacuating  cannula,  upper  arrow  on 
right  ;  lower  arrow  on  right  points  to  small 
fragments  of  crushed  calculus,  arrow  on  left 
to  large  fragment  that  could  not  pass  the  eye 
of  the  cannula.     (P.   503.) 


Plate  37. 


XX  W I 


LITHOLAPAXY 


505 


crushed ;  and  this  maiKjeiivro  is  repeated  until  no  fragments  are 
left.  Tlie  beak  is  now  turned  to  the  other  side,  and  the  process 
repeated.  All  the  fragments  having  been  crushed,  the  blades  arc 
closed  and  the  lithotritc  witlidrawji. 

The  largest  cannula  that  the  urethra  will  admit  is  now  passed 
and  the  fluid  in  the  bladder  allowed  to  escape.  Four  or  five  ounces 
are  again  injected,  the  aspirator  bulb  is  applied  to  the  cannula, 
and  the  cock  opened.  The  bulb  is  now  raised  in  the  middle  line, 
so  that  the  beak  of  the  cannula  lies  at  the  lowest  part  of  the 


Fig.  159. — Litholapaxy  :    Removal  of  the  crushed  fragments 
by  evacuator. 

The  beak  of  the  evacuating  cannula  is  at  the  most  dependent  part  of  the  bladder.     It  is  supported 

by  the  left  hand,  and  the  eye  has  been  turned  towards  the  onlooker  by  pressing  the  thumb  on  the 

flange.     The  right  hand  is  in  the  act  of  squeezing  the  bulb. 

bladder,  and  the  bulb  is  grasped  in  the  right  hand  and  compressed, 
the  cannula  being  firmly  held  by  the  left  hand.  At  diastole  of  the 
bulb  the  fragments  of  the  stone  are  sucked  into  the  rubber  bulb, 
and,  being  heavier  than  water,  they  fall  down  into  the  glass  bulb. 
The  aspiration  is  continued  until  no  further  fragments  fall,  then  the 
beak  of  the  cannula  is  turned  to  the  right  and  aspiration  repeated, 
and  then  to  the  left,  each  new  position  being  retained  until  the 
supply  of  fragments  is  exhausted  at  that  spot.  During  diastole 
there  may  be  "  stammering  "  of  the  suction,  which  indicates  that 
the  beak  of  the  cannula  has  been  applied  too  close  to  the  wall 
of  the  bladder  and  the  loose  mucous   membrane  sucked  into  the 


506  THE   BLADDER  [chaf. 

eye.  This  miigt  be  avoided,  as  it  is  tantamount  to  dry-cupping 
the  wall  of  the  bladder.  If  it  should  happen,  the  eye  is  set  free 
by  compressing  the  bulb,  and  is  then  turned  away  from  the 
mucous  membrane. 

Two  aspiration  bulbs  should  be  in  use,  to  save  time  by  chang- 
ing them  when  one  is  filled  or  the  fluid  has  become  cloudy.  The 
bulb  may  become  fixed  and  fail  to  expand.  This  is  due  either  to 
aspiration  of  the  mucous  membrane,  and  is  freed  by  squeezing 
the  bulb  and  turning  the  eye  away  from  the  mucous  membrane, 
or  to  a  fragment  of  stone  too  large  to  pass  the  cannula  becoming 
fixed  in  the  eye.  This  may  be  dislodged  in  the  same  way,  but 
will  probably  necessitate  the  bulb  being  detached  from  the  can- 
nula and  a  stylet  being  pushed  along  the  tube,  after  which  the 
fluid  comes  away  in  a  gush. 

When  removal  of  the  stones  is  complete  the  fragments  cease 
to  fall  into  the  glass  bulb  at  diastole,  and  on  listening  carefully 
no  click  of  a  fragment  against  the  eye  of  a  cannula  can  be  heard. 
Frequently  at  the  end  of  the  crushing  several  large  greyish-white 
shreds  of  muco-pus  and  necrosed  epithelium  fall  into  the  bulb. 
This  is  the  bed  on  which  the  stone  has  been  lying.  If  the  clicking 
of  fragments  can  still  be  heard  the  lithotrite  is  again  introduced, 
and  the  fragments  are  crushed,  and  removed  by  the  aspirator. 

The  type  of  fragment  which  is  most  difficult  to  pick  up  with 
the  lithotrite  is  a  thin  shell  from  the  outer  part  of  the  calculus. 

The  bladder  is  now  washed  out  through  the  cannula  with 
nitrate  of  silver  solution  (1  in  10,000),  and  the  cannula  removed. 
If  the  fluid  returns  clear  on  washing  the  bladder  a  cystoscope 
may  be  introduced  and  the  bladder  examined  to  see  that  it  is 
clear  of  fragments.  Usually,  however,  the  cystoscopy  may  be 
deferred  for  a  few '  days.  The  operation  lasts  from  five  or  ten 
minutes  to  an  hour  or  more,  according  to  the  size  of  the  stone 
and  the  condition  of  the  bladder. 

If  cystitis  is  present,  or  if  the  bladder  is  irritable  or  the  pros- 
tate enlarged,  the  bladder  should  be  drained  by  tying  a  catheter 
in  the  urethra  for  a  few  days,  and  should  be  washed  daily  with 
silver  nitrate  solution.  The  patient  is  kept  in  bed  from  two  to 
fourteen  days,  according  to  the  condition  of  the  bladder  and  the 
temperature.  Three  to  five  days  will  suffice  when  the  stone  is 
small  and  the  bladder  aseptic. 

Litholapaxy  in  children. — There  are  theoretical  objections 
against  the  performance  of  litholapaxy  in  children.  The  urethra 
is  very  small  and  narrow,  and  its  mucous  membrane  delicate  and 
easily  torn,  and  the  bladder  is  small  and  pear-shaped,  so  that  the 
space  for  manipulation  is  confined. 


xxxvT]  LITHOLAPAXY  IN   CHILDREN  50? 

Keegan  has  shown,  Iiowcvcm-.  that  lithohi[)axy  in  yoiii)<i;  cliihlion 
is  not  only  possible,  hut  is  prc^ftM'ahlc  to  other  methods,  i^'ieyer 
has  further  established  this  operation  on  a  sound  basis.  The 
latter  authority  advises  that  the  surgeon  be,  provided  with  a  series 
of  small  instruments  similar  to  those  used  in  adults,  ranging  from 
No.  4^  to  10.  Boys  aged  from  13  to  16  take  a  lithotrite  of  No.  11 
or  12  size  ;  while  the  cannula)  suitable  for  children  vary  from 
No.  6  to  11  English  scale.  The  small  sizes  of  cannulae  should  be 
short,  as  the  suction  power  is  diminished  by  the  small  lumen. 
The  aspirator  is  used  with  the  utmost  gentleness,  and  only  a  small 
quantity  of  water  is  pressed  into  the  bladder  at  each  systole.  The 
calibre  of  the  urethra  varies  more  in  the  child  than  in  the  adult. 
The  meatus  and  first  inch  and  a  half  are  the  narrowest  part  of 
the  ufethra  in  the  child.  Having  passed  this,  the  lithotrite  enters 
the  bladder  without  further  difficulty,  except  a  slight  hitch  at 
the  interna]  meatus.  The  operation  in  children  takes  longer,  and 
there  is  more  danger  of  leaving  fragments  behind,  but  this  can 
be  avoided  by  care  and  experience. 

If  the  lithotrite  does  not  lie  easily  in  the  canal,  there  may 
be  difficulty  in  withdrawing  and  reintroducing  instruments.  For 
this  reason  care  should  be  taken  to  finish  the  crushing  before 
withdrawing  the  lithotrite.  The  earliest  age  at  which  litholapaxy 
can  be  performed  depends  upon  the  calibre  of  the  urethra.  Freyer 
performed  the  operation  on  a  male  child  aged  18  months.  In 
January,  1912,  the  author  performed  litholapaxy  on  a  boy  aged 
15  months.  The  stone  consisted  of  calcium  phosphate.  Metal 
sounds  up  to  10  English  gauge  were  passed  before  the  urethra 
would  accommodate  the  lithotrite.  The  difficulty  lay  in  the 
first  inch  and  a  half  of  the  urethra.  After  crushing  the  stone 
there  was  some  difficulty  in  removing  the  lithotrite,  as  it  was 
firmly  gripped  at  the  internal  meatus.  The  size  of  the  lithotrite 
and  evacuating  cannula  was  11  Fr. 

Litholapaxy  in  tiie  female. — The  operation  presents  no  diffi- 
culty in  the  female  subject.  The  shank  of  the  instrument  should 
be  well  lubricated,  so  that  it  does  not  drag  on  the  labia  majora, 
and  if  there  is  any  tendency  to  incontinence  an  assistant  presses 
the  forefinger  against  the  urethra  from  the  vagina  during  the 
operation. 

Difficulties  and  contra-indications  of  litholapaxy.  i.  The 
urethra. — The  external  meatus  is  frequently  too  narrow  to  admit 
a  large  lithotrite,  and  meatotomy  should  be  performed  before 
commencing  the  operation.  Stricture  of  the  urethra  may  pre- 
vent the  introduction  of  the  lithotrite.  In  all  cases  of  vesical 
calculus  the   urethra   should  be   examined  before   operation,   and 


508  THE   BLADDER  [chap. 

large  somids  passed  to  estimate  the  calibre  of  the  tube.  The 
adult  urethra  should  have  a  capacity  of  16  or  18  English  scale 
(28  to  30  Fr.)  for  large  lithotrites,  and  12  or  13  (21  to  23  Fr.)  for 
small  lithotrites.  There  may  be  difficulty  in  passing  through 
the  membranous  urethra,  from  spasm  of  the  compressor  urethrse. 
A  large  metal  instrument  should  first  be  passed,  and  the  litho- 
trite  will  readily  follow.  Organic  stricture  must  be  treated  before 
the  lithotrite  can  be  passed.  This  may  be  done  at  the  time  of 
the  litholapaxy.  Internal  urethrotomy  is  performed  and  large 
metal  instruments  are  passed,  the  bladder  filled  with  fluid,  and 
then  the  lithotrite  used.  I  prefer  to  treat  the  two  conditions 
separately,  allowing  a  fortnight's  interval  to  elapse  between  the 
internal  urethrotomy  and  the  litholapaxy,  for  the  passage  of 
large  irregular  instruments  like  the  lithotrite  and  cannulse  several 
times  through  a  urethra  the  seat  of  an  internal  urethrotomy  wound 
causes  minecessary  bruising  and  tearing  of  the  incision,  and  may 
lead  to  recontraction  of  the  stricture  at  a  later  date.  The  narrow 
urethra  of  the  child  in  relation  to  litholapaxy  has  already  been 
discussed. 

ii.  Enlarged  'prostate. — A  moderate  enlargement  of  the  pros- 
tate is  not  a  barrier  to  litholapaxy,  but  a  large  prostate  causes 
considerable  difiiculty  in  the  introduction  of  the  lithotrite,  and  a 
well- developed  intravesical  projection  hampers  the  movements 
of  the  lithotrite,  so  that  stones  wedged  behind  it  are  reached  with 
difficulty  by  the  lithotrite.  Haemorrhage  may  be  severe.  The 
best  method  of  treatment  of  stone  with  enlarged  prostate  is  supra- 
pubic prostatectomy  with  removal  of  the  stones.  There  is  no 
difficulty  in  performing  litholapaxy  in  cases  of  recurrent  stone 
where  prostatectomy  has  previously  been  done.  When  a  stone 
forms  in  or  passes  into  the  cavity  left  after  prostatectomy  it  may 
sometimes  be  manipulated  back  into  the  bladder  by  means  of 
the  lithotrite  or  a  large  metal  sound,  and  it  is  sometimes  possible 
to  crush  it  in  the  prostatic  cavity  with  a  small  lithotrite,  but  as 
a  rule  a  median  perineal  incision  will  be  necessary  for  the  removal 
of  the  stone. 

iii.  The  hladder. — In  acute  cystitis  the  bladder  does  not  hold 
sufficient  fluid  to  allow  of  litholapaxy  being  performed.  The  patient 
should  be  confined  to  bed,  and  treatment  for  acute  cystitis  adopted. 
Litholapaxy  may  be  performed  when  the  cystitis  has  subsided. 
If,  however,  improvement  is  tardy,  suprapubic  lithotomy  and 
drainage  of  the  bladder  is  preferable. 

In  chronic  cystitis  litholapaxy  should  be  performed  and  the 
cystitis  actively  treated. 

Advanced  sacculation  of  the  bladder  should  be  looked  upon  as 


XXXVI]         LITHOLAPAXY:   DIFFICULTIES  509 

a  contra-inclication  to  litholapaxy.  The  fragments  and  powder 
fall  into  the  saccules,  and  are  not  removed  by  the  aspirator.  A 
stone  in  a  saccule  is  unsuitable  for  litholapaxy.  Such  stones  have 
been  crushed,  but  there  is  a  danger  of  injury  to  the  bladder  wall 
and  of  rupture  of  the  thin-walled  saccules  that  should  deter  the 
surgeon  from  using  this  method. 

Spasmodic  contraction  of  the  bladder  around  the  stone  at  the 
upper  part  of  the  bladder,  forming  a  species  of  hour-glass  bladder, 
may  develop ;  and  a  similar  condition  in  children  at  the  lower 
part  of  the  bladder  may  interfere  with  the  intravesical  manipula- 
tion. This  contraction  may  relax  after  a  time,  but  in  one  case 
of  an  adult  at  the  upper  part  of  the  bladder,  and  in  two  cases  of 
children  at  the  lower  part,  I  have  had  to  abandon  litholapaxy  and 
remove  the  tightly  wedged  stones  by  suprapubic  lithotomy. 

New  growths  of  the  bladder  when  combined  with  stone 
contra-indicate  litholapaxy. 

iv.  Size  of  the  stone. — No  rule  can  be  laid  down  as  to  the  limits 
of  size  that  are  suitable  for  htholapaxy.  Large  stones  which  are 
egg-shaped  may  be  crushed  when  grasped  in  the  short  axis,  when 
the  long  axis  is  too  great  for  the  grasp  of  the  lithotrite. 

Very  large  stones-  are  more  quickly  and  safely  removed  by 
suprapubic  cystotomy  with  drainage  of  the  bladder  than  by  litho- 
lapaxy. Stones  that  are  too  hard  for  crushing  by  a  well-made 
lithotrite  are  very  rare,  if  other  conditions  be  favourable.  When 
the  lithotrite  is  fully  screwed  up  on  a  very  hard  calculus,  fracture 
may  be  delayed  for  quite  an  appreciable  interval. 

Perineal  litholapaxy. — A  median  external  urethrotomy  is 
made  on  a  grooved  staff  and  the  membranous  urethra  opened 
longitudinally.  A  large-sized  Bigelow  lithotrite  is  introduced,  or 
a  Harrison's  lithoclast,  and  the  stone  crushed  and  removed  by 
an  evacuator  or  forceps.  It  is  claimed  that  this  operation  is 
useful  when  it  is  desired  to  examine  the  prostatic  urethra  and 
remove  the  prostate  by  the  perineum.  There  may  be  difficulty 
in  grasping  the  stone.  The  operation  is  inferior  to  litholapaxy 
and  to  suprapubic  lithotomy. 

Dangers  of  litholapaxy. — Ascending  pyelonephritis  is  a  rare 
sequel  in  septic  cases.  These  cases  should  be  carefully  prepared 
by  washing  and  urinary  antiseptics  before  the  operation,  and 
drainage  of  the  bladder  by  catheter  should  be  installed  after  the 
operation.  When  the  urine  is  septic  a  sharp  rise  of  temperature 
may  follow  the  operation  from  absorption  of  septic  material  from 
the  urethra,  which  may  have  suffered  some  slight  mechanical 
injury  during  the  operation.  This  can  be  prevented  by  thorough 
preparation  of  the  bladder  before,  and  by  drainage  with  a  catheter 


510  THE   BLADDER  [chap. 

after  the  operation,  and  it  is  less  likely  to  occur  when  skill  and 
gentle  manipulation  have  been  exercised  than  when  the  urethra 
has  been  roughly  handled.  Haemorrhage  may  result  from  enlarge- 
ment of  the  prostate,  from  growth  in  the  bladder,  or  from  unskilful 
manipulation. 

Perforation  of  the  bladder  wall  has  occurred,  and  has  appar- 
ently been  due  to  operating  in  a  small  contracted  bladder  con- 
taining an  insufficient  quantity  of  fluid.  The  perforation  is  situated 
immediately  behind  the  trigone  and  is  extraperitoneal,  and  allows 
fluid  and  fragments  to  escape  into  the  pelvic  cellular  tissue.  Pelvic 
cellulitis  and  peritonitis  supervene,  and  unless  promptly  treated 
by  free  drainage  are  fatal. 

2.  Suprapubic  lithotomy. — The  bladder  is  exposed  and 
opened  by  a  vertical  median  suprapubic  incision,  and  the  left  fore- 
finger passed  into  the  cavity.  A  pair  of  lithotomy  forceps  is 
introduced,  and,  guided  by  the  finger,  grasps  and  removes  the 
stone.  A  number  of  calculi  may  be  removed  in  this  way  or  by 
means  of  a  scoop.  When  there  are  numerous  small  stones,  or 
when  a  friable  phosphatic  stone  is  removed,  great  care  must  be 
exercised  to  avoid  leaving  small  stones  or  fragments  in  the  bladder 
or  in  the  perivesical  space  in  withdrawing  them.  A  copious  stream 
of  fluid  from  a  large  reservoir  is  useful  for  removing  debris  and 
small  stones.  In  dealing  with  large  calculi  the  wound  in  the 
bladder  should  be  sufficiently  large  to  pass  the  stone  without  tear- 
ing or  bruising.  The  bladder  wall  may  have  to  be  peeled  off  a 
large  calculus.  When  the  prostate  is  enlarged,  prostatectomy 
should  immediately  follow  removal  of  the  calculi.  The  treatment 
of  a  calculus  in  a  diverticulum  depends  upon  whether  the  cal- 
culus is  shut  in  a  diverticulum  which  communicates  with  the  bladder 
by  a  small  opening,  or  whether  the  opening  is  large  and  the  cal- 
culus easily  accessible  or  projecting  into  the  bladder  cavity.  In 
the  former  case  the  treatment  is  described  under  that  of  diverti- 
cula (p.  411).  In  the  latter  the  calculus  is  grasped  by  lithotomy 
forceps  guided  by  the  forefinger,  or,  if  the  calculus  is  impacted  or 
difficult  to  reach,  the  patient  is  placed  in  the  Trendelenburg  position 
and  the  operation  conducted  under  the  light  of  a  head-lamp,  the 
opening  of  the  diverticulum  being  enlarged  if  necessary.  A  large 
calculus  in  a  diverticulum  has  been  broken  up  by  a  chisel  and 
mallet,  counterpressure  being  obtained  by  the  finger  of  an  assistant 
in  the  rectum.  The  fragments  were  then  extracted.  In  such 
cases  it  is  better  to  remove  the  diverticulum  by  dissection  out- 
side the  bladder,  and  with  it  the  stone. 

After  suprapubic  lithotomy,  drainage  by  means  of  a  large 
rubber  tube  should  be  installed  in  cases  where  cystitis  or  a  diver- 


xxxvij  PERINEAL   LITHOTOMY  511 

ticulum  or  urethral  obstruction  is  present,  or  where  the  kidneys  are 
diseased  by  sepsis  or  back  pressure.  A  smaller  tube  is  placed  in 
the  prevesical  space,  and  both  are  removed  on  the  fourth  day. 
The  bladder  is  washed  daily  with  solutions  of  nitrate  of  silver 
(1  in  10,(X)0  to  1  in  5,000)  or  some  other  antiseptic. 

When  a  small  calculus  is  removed  from  an  aseptic  bladder  the 
cystotomy  wound  may  be  completely  closed  and  a  catheter  tied 
in  the  urethra. 

Median  perineal  lithotomy. — A  curved  staff  with  median 
groove  is  introduced  into  the  bladder  and  the  patient  placed  in 
the  lithotomy  position.  The  handle  of  the  staff  is  held  vertically 
by  an  assistant,  who  grips  the  handle  of  the  instrument  with  the 
right  hand,  and  includes  the  lowest  part  of  the  scrotum  in  this 
grasp.  An  incision  2  in.  in  length  is  made  from  above  downwards 
in  the  middle  line  of  the  perineum,  ending  J  in.  in  front  of  the 
anus.  This  js  deepened  to  the  membranous  urethra,  which,  is 
opened  longitudinally  on  the  staff,  and  the  point  of  the  knife  is 
run  longitudinally  along  the  groove  till  it  reaches  the  prostatic 
urethra.  A  probe-pointed  gorget  is  introduced  and  pushed  along 
the  groove,  and  the  surgeon  draws  the  handle  of  the  stafi  towards 
him  and  at  the  same  time  pushes  the  gorget  on  into  the  bladder, 
when  a  gush  of  urine  escapes.  The  staff  is  withdrawn  and  the 
forefinger  of  the  left  hand  introduced  along  the  gorget  into  the 
bladder,  and  the  gorget  withdrawn.  Forceps  or  a  scoop  is  passed 
along  the  finger  into  the  bladder,  and  the  stone  removed. 

A  rubber  perineal  drainage  tube  is  tied  in  the  bladder  and  kept 
there  for  a  few  days. 

Lateral  lithotomy  is  iiow  abandoned  in  favour  of  one  of  the 
methods  already  described. 

Vaginal  lithotomy  consists  in  opening  the  bladder  on  a  sound 
from  the  anterior  vaginal  wall.  The  operation  is  inferior  to  those 
described,  and  vesico-vaginal  fistula  is  a  frequent  sequel. 

Choice  of  operation  for  vesical  calculus. — Only  two 
methods,  litholapaxy  and  suprapubic  lithotomy,  need  be  dis- 
cussed. The  advantages  of  Htholapaxy  are  that  it  is  applicable 
to  the  great  majority  of  calculi,  and  that  in  recurrent  calculi  it 
may  be  repeated  time  after  time  without  increased  difficulty. 
The  death-rate  in  experienced  hands  is  low  and  the  convalescence 
rapid.  This  operation  is  unsuitable  for  very  large  stones,  encysted 
stones,  stones  in  a  sacculated  bladder,  for  cases  of  enlarged  pros- 
tate, foul  cystitis,  or  those  in  which  advanced  pyelonephritis  is 
present. 

Suprapubic  lithotomy  requires  less  manipulative  skill  and  has 
the  advantage  of  providing  thorough  postoperative  drainage.     It 


512 


THE  BLADDER 


[chap. 


is  thus  especially  useful  in  cases  of  foul  cystitis  and  those  in  which 
there  is  urethral  obstruction.  It  should  be  performed  in  cases 
of  encysted  stone,  of  very  large  calculi,  where  the  kidneys  are 
diseased,  of  enlarged  prostate,  and  of  bladder  growths.  In  stone 
complicating  bilharziosis  or  cystitis,  lithotomy  is  preferable  to 
litholapaxy,  and  the  perineal  operation  is  invariably  performed. 
In  other  cases  it  has  the  disadvantage  of  a  longer  period  of  con- 
valescence (fourteen  to  twenty-one  days),  the  death-rate  is  higher, 
and  in  recurrent  calculus  the  succeeding  cystotomy  becomes 
increasingly  difficult. 

Litholapaxy  should  be  performed  as  the  routine  operation, 
and  lithotomy  reserved  for  cases  that  are  unsuitable  for  crushing. 
The  proportion  in  which  a  cutting  operation  is  necessary  is  small. 
Of  66  cases  of  vesical  calculus  treated  in  St.  Peter's  Hospital  during 
the  year  1910,  litholapaxy  was  performed  in  56  with  1  death, 
suprapubic  lithotomy  was  performed  3  times  with  1  death, 
and  prostatectomy  with  removal  of  calculi  in  7  cases  without 
a  death.  In  children  litholapaxy  is  a  very  successful  operation, 
and  cystotomy  should  be  reserved  for  cases  in  which  the  urine 
is  foul,  or  the  calculus  is  very  tightly  wedged  in  the  neck  of  the 
bladder,  or  the  urethra  is  too  small  to  admit  a  lithotrite. 

Results. — The  following  are  the  results  in  1,814  cases  of  stone 
in  the  bladder  operated  on  at  St.  Peter's  Hospital  from  1864  to 
1912  :— 

Cured  or 
relieved 

100 

166 

332 

571 

520 

The  proportion  of  the  different  operations  has  already  been  given. 
The  decline  of  the  death-rate  under  the  aseptic  performance  of 
litholapaxy  is  very  striking. 

Sir  Henry  Thompson  recorded  49  deaths  in  850  cases  of  litho- 
trity,  a  mortality  of  5-76  per  cent.  Only  372  of  these  operations 
were  performed  according  to  the  modern  Bigelow  method  at  one 
sitting,  and  in  these  the  mortality  was  3-22  per  cent. 

The  death-rate  of  litholapaxy  in  the  hands  of  various  surgeons 
is  as  follows  : — 


Decade 


Operations 


1864-73 

118 

1874-83 

196 

1884-93 

362 

1894-1903 

600 

1904-12 

538 

, 

Death-rate 

'ted 

{per  cent.) 

18 

15-25 

30 

15-30 

30 

8-29 

29 

4-83 

18 

3-34 

Guyon 

2-7  per  cent 

Zuckerkandl 

3-6 

V.  Friscli 

2-6 

Legueu 

20 

Freyer 

2-61       „ 

XXXVI]    RESULTS   OF   STONE   OPERATIONS  513 

In  19  cases  of  swprapuhic  lithotomy  Thompson  had  5  deaths 
(26-3  per  cent.),  and  in  149  cases  Freyer  had  19  deaths  (12-75 
per  cent.). 

The  high  death-rate  of  suprapubic  lithotomy  compared  with 
litholapaxy  is  due  to  the  fact  that  all  the  grave  cases  were  treated 
by  lithotomy.  When  the  same  cases  are  treated  by  the  two  opera- 
tions the  results  are  less  disproportionate.  Thus,  Assenfeldt  in  460 
cases  of  suprapubic  lithotomy  found  a  death-rate  of  3-6  per  cent. 

Late  results. — Watson  found  19  per  cent,  of  recurrence  in 
902  cases  of  litholapaxy,  and  in  more  than  two-thirds  of  these 
the  patients  were  over  50  years  of  age.  There  is  no  difference 
in  recurrence  after  the  two  operations  of  lithotomy  and  litho- 
lapaxy in  the  hands  of  an  experienced  surgeon.  Recurrence 
takes  place  most  frequently  from  new  formation  of  phosphatic 
stones,  usually  in  the  subjects  of  enlarged  prostate.  Recurrence 
of  oxalate-of-lime  and  uric-acid  calculi  is  much  less  frequent, 
but  may  occur  from  the  descent  of  calculi  from  the  kidney  or  by 
new  formation  in  the  bladder.  The  latter  is  very  rarely  the  result 
of  fragments  left  behind  at  a  crushing  or  cutting  operation.  The 
recurrent  calculus  after  removal  of  a  uric-acid  or  oxalate-of-lime 
calculus  may  be  phosphatic,  and  is  due  to  changes  in  the  urine. 
The  efSect  of  removal  of  an  enlarged  prostate  upon  the  recurrence 
of  calculi  varies  according  to  their  composition  and  the  state 
of  the  urine.  Uric-acid  and  oxalate-of-lime  calculi  rarely  recur, 
phosphatic  calculi  frequently.  In  7  out  of  112  cases  of  prostatec- 
tomy in  which  the  author  removed  calculi  at  the  time  of  the 
operation  there  was  no  recurrence  in  4,  and  all  these  were  cases 
of  uric-acid  or  oxalate-of-lime  calculi.  In  the  remaining  3  cases 
the  urine  was  alkaline  and  the  stones  were  phosphatic,  and  there 

was  recurrence  in  all. 

LITERATURE 
Assenfeldt,  Arch.  f.  hlin.  Chir.,  1899,  p.  669. 
Civiale,  Traite  de  r Affection  Calculeuse.     Paris,  1838. 
Dykes,  Lancet,  1910,  i.  566. 
d'Etoilles,  Leroy,  Union  Med.,  1855. 
Freyer,  Surgical  Diseases  of  the  Urinary  Organs.     19U8. 
Heller,  Die  Harnkonkretionen.     Wien,  1860. 
Histon,  Brit.  Med.  Journ.,  1904,  ii.  833. 
Kapsamraer,  Wien.  klin.  Woch.,  1903. 
Kasarnowsky,  Folia  Urol.,  1909,  p.  469. 
Keegan,  Ind.  Med.  Gaz.,  1885. 
Knorr,  Zeits.  f.  Geb.  u.  Gyn.,  1911,  Heft  i. 
Milton,  Lancet,  1893,  p.  687. 
Ord,  Trans.  Path.  Soc.   Loud.,   1878. 
Petit,   Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1904,  p.  1281. 
Walker,  Thomson,  IP  Congres  de  I'Assoc.  Internat.  d'Urol.,  London,  1911. 
Watson,  Boston  Med.  and  Surg.  Journ.,  Dec.  2,  1886 
Wildt,  1*="^  Congres  Egyptien  de  Med.,  Cairo,  1905. 

Zuckerkandl,  Handbuch  dcr  Urologic  (von  Frisch  und  Zuclierkandl),  1905,  B.  ii. 
2h 


CHAPTEE  XXXVII 
FOREIGN  BODIES  IN  THE  BLADDER 

Foreign  bodies  reach  tlie  bladder  by  the  urethra  or  through 
the  bladder  wall. 

A  silk  suture  placed  in  the  bladder  wall  at  an  operation  acts 
as  a  foreign  body  and  forms  the  nucleus  of  a  calculus.  A  number 
of  such  calculi  may  be  found  when  silk  has  been  used  as  suture 
material.  (Figs.  152,  153.)  Soft  absorbable  catgut  should  there- 
fore be  used  in  all  bladder  operations. 

A  silk  ligature  used  in  operations  upon  the  pelvic  viscera,  such 
as  ovariotomy  or  hysterectomy,  may  later  penetrate  the  bladder 
wall  and  act  as  a  foreign  body.  A  mop  or  gauze  roll  may  be  acci- 
dentally left  in  the  bladder  at  the  time  of  an  operation.  The 
flexible  guide  of  a  urethrotome  may  become  detached  from  the 
instrument  by  being  imperfectly  screwed  on,  or  it  may  break 
across  the  junction  of  the  flexible  and  metal  portion.  To  avoid 
this  the  metal  part  should  taper  inside  the  flexible.  Portions  of 
rubber  or  gum-elastic  catheters  which  are  old  and  friable  may 
break  off  and  remain  in  the  bladder. 

Foreign  bodies  may  be  introduced  by  the  patient  along  the 
urethra  by  design,  either  in  innocence  or  to  excite  erotic  sensa- 
tions, and  the  bodies  may  slip  into  the  bladder.  This  occurs 
more  frequently  in  the  short  female  urethra  than  in  the  long, 
tortuous  male  canal.  I  have  seen  in  the  female  bladder  a  coiled 
piece  of  wire,  a  hairpin,  a  pin ;  and  in  the  male  a  collar-stud 
buttoner,  a  metal  pencil-case,  a  cylindrical  piece  of  hard  wax. 
(Plate  38,  Figs.  1,  2.) 

The  following  are  a  few  of  the  articles  which  have  been  found, 
viz. :  needle,  bone  knitting-needle,  rubber  tube,  thermometer,  glass 
rod,  nozzle  of  an  irrigating  apparatus,  pessary,  mouthpiece  of  a 
pipe.  A  splinter  of  bone  from  a  bone  abscess  or  after  fracture  of 
the  pelvis  has  penetrated  the  bladder  wall.  A  pair  of  artery 
forceps,  left  in  the  pelvis  at  a  gynaecological  operation,  has  been 
known  to  ulcerate  through  the  bladder  wall  (Spencer  Wells). 

Effect  upon  the  bladder. — Unless  the  body  is  sharp  and 
irritating,  it  remains  for  a  week  or  more  without  giving  rise  to 

514 


Fig.   1. — Stud-buttoner     covered     with     phosphatic 
deposit  in  male  bladder.     (P.  514.) 

Fig.  2. — Doubled-up   piece    of    wax    in   male   blad- 
der.    (P.  514.) 
Fig.  3. — Atrophy  of  bladder  wall  in  tabes  dorsalis. 

(P.  534.) 


Plate  38. 


CHAP.  XXXVII]     FOREIGN   BODIES:   SYMPTOMS        515 

irritation  ;  at  the  end  of  tliat  time,  or  even  sooner,  the  mucous 
membrane  becomes  inflamed  at  the  situation  usually  occupied  by 
the  foreign  body,  and  in  patches  elsewhere  which  come  in  con- 
tact with  it.  Ulceration  and  even  penetration  of  the  bladder 
wall  may  follow.  Penetration  of  the  body  into  the  bowel  or 
vagina  may  occur.  The  foreign  body  quickly  becomes  encrusted 
with  phosphatic  deposit,  and  this  occurs  when  the  urine  is  still 
clear.  According  to  Zuckerkandl,  wax  does  not  become  encrusted, 
silver  slowly,  while  iron,  rubber,  and  vegetable  materials  are  most 
rapidly  coated.  A  phosphatic  stone  forms,  and  may  reach  large 
dimensions.  A  portion  only  of  an  elongated  body  may  become 
covered  with  phosphates — only  the  head  of  a  pin,  and  in  a  needle 
the  sharp  end,  projects.  Long  flexible  bodies,  such  as  catheters 
■or  urethrotome  guides,  may  form  knots.  Finally,  infection  occurs, 
and  the  urine  becomes  alkaline  and  offensive.  Very  rarely  a 
calculus  forms  in  acid  urine.  Zuckerkandl  describes  a  large  uric- 
acid  calculus  which  formed  around  a  fragment  of  iron. 

Symptoms. — For  some  hours  after  the  introduction  of  the 
body  there  is  vesical  irritation,  but  this  may  subside,  and  for  a 
varying  time  symptoms  may  be  absent.  Smooth,  regular  bodies 
may  remain  quiescent  .unless  they  are  swept  into  the  internal 
meatus,  when  retention  of  urine  results.  Later  there  is  increased 
frequency  of  micturition,  with  pain,  the  urine  becomes  turbid, 
and  infection  takes  place.  The  symptoms  are  then  similar  to 
those  of  stone  in  the  bladder.  Retention  of  urine  is  common 
when  the  body  has  penetrated  the  bladder  wall,  pericystitis 
results,  and  there  is  high  fever  with  pelvic  pain,  and  a  swelling 
can  be  detected. 

When  a  mop  or  a  gauze  roll  is  left  in  the  bladder  after  an 
-operation  there  is  unusually  severe  and  prolonged  vesical  spasm. 
The  urine  may  remain  aseptic  for  several  weeks,  but  afterwards 
becomes  infected.  The  suprapubic  sinus  remains  open,  and 
eventually  the  body  appears  at  the  womid,  or  is  removed  at 
an  exploratory  operation. 

Diagnosis.— The  history  of  the  introduction  of  the  foreign 
body  may  be  difficult  to  elicit,  and  the  patient  is  examined  for 
spontaneous  persistent  cystitis.  In  the  course  of  this  examination 
the  foreign  body  is  discovered  with  the  cystoscope.  Its  usual 
situation  is  on  the  posterior  wall  behind  the  trigone.  In  the  case 
of  a  long  body,  one  end,  when  the  bladder  is  distended,  is  near 
the  internal  meatus,  and  the  body  lies  obliquely  towards  one  or 
other  side  ;  when  the  bladder  is  empty,  the  body  lies  transversely. 
The  gradual  onset  of  cystitis  some  time  after  an  operation  on 
the  pelvic  viscera,  or  the  development  of  stone  after  an  operation 


516  THE  BLADDER  [chap,  xxxvii 

in  which,  silk  is  known  to  have  been  used  as  suture  material, 
or  the  presence  of  an  inflammatory  mass  alongside  the  bladder 
detected  by  rectal,  vaginal,  or  bimanual  examination,  should 
arouse  the  suspicion  that  a  foreign  body  may  be  present. 

The  X-rays  may  assist  when  the  foreign  body  is  opaque. 

Treatment. — Urethral  operations  are  most  suitable  for  the 
female  subject,  but  are  also  feasible  in  some  cases  in  the  male. 
In  the  female  a  large  Kelly's  tube  should  be  used  after  dilatation 
of  the  urethral  orifice,  and  the  patient  placed  in  the  Trendelen- 
burg position.  When  the  bladder  is  distended  with  air  the  foreign 
body  may  be  seized  with  fine  forceps  or  with  specially  constructed 
instruments  and  removed.  The  manoeuvres  may  be  assisted  by 
a  finger  in  the  vagina.  There  may  be  difficulty  in  obtaining 
inflation  of  the  bladder  or  in  seizing  the  foreign  body.  In  the 
male,  urethral  operations  are  less  likely  to  be  successful.  Luys' 
direct  cystoscope  should  be  used,  and  the  patient  placed  in  the 
Trendelenburg  position.  A  catheter  or  urethrotome  guide  may 
be  seized  "v\nth  a  lithotrite  and  removed. 

When  these  methods  fail  (50  per  cent,  of  cases)  the  bladder 
should  be  opened  suprapubically  and  the  foreign  body  extracted- 
If  a  septic  cystitis  or  ulceration  is  present  and  no  penetration  of 
the  wall  of  the  bladder  has  occurred  the  cystotomy  wound 
should  be  sutured,  but  in  the  other  cases  a  large  suprapubic 
drain  should  be  introduced. 

When  a  foreign  body  such  as  a  hair-pin  forms  the  centre  of 
a  calculus  the  ends  usually  project,  so  that  a  diagnosis  can  be 
made.  The  calculus  should  be  removed  by  suprapubic  cyst- 
otomy. In  other  cases  a  foreign-body  nucleus  is  entirely  buried 
in  a  calculus,  and  is  only  revealed  by  the  difficulty  experienced 
in  crushing  this  part  of  the  calculus  or  by  the  peculiar  sensation 
imparted  on  grasping  it  with  the  lithotrite.  Such  bodies  are 
usually  small,  and  may  be  broken  up  with  the  lithotrite.  If  this. 
fails  the  bladder  should  be  opened  and  the  object  removed. 

LITEEATURE 

Grosglik,   CentralU.  /.  d.   Krankh.  d.  Ham-  u.  Sex.-Org.,  1897,  p.  641. 

Heresco,  Ann.  d.  Mai.  d.  Org.  Oen.-Urin.,  1898,  p.  802. 

Hirsch,  Deuts.  Zeits.  f.  Chir.,  1903,  p.  45. 

Ravasini,  Wien.  med.  Pre-sse,  1902,  p.  31. 

Zuckerkandl,  Handhuch  der  Uwlogie  (von  Frisch.  imd  Zuckerkandl),1905,  B.  iL 


CHAPTER  XXXVIII 
PERICYSTITIS  AND  PERIVESICAL  ABSCESS; 

The  perivesical  tissue  consists  of  fatty  and  areolar  tissue,  and 
forms  part  of  the  freely  intercommunicating  areolar  planes  of 
the  pelvis,  which  partly  surround  the  bladder,  rectum,  uterus, 
and  vagina,  and  lie  between  the  layers  of  the  broad  ligament  in 
the  female.  They  communicate  above  with  the  areolar  tissue 
of  the  iliac  fossae,  closely  related  with  the  caecum  and  appendix 
on  the  right  and  the  sigmoid  flexure  on  the  left  side.  In 
front  of  the  bladder  there  is  a  space  (the  space  of  Retzius), 
limited  anteriorly  by  the  pubic  bones  and  filled  with  loose  areolar 
tissue.  A  partial  floor  is  formed  by  the  anterior  extremities  of 
the  visceral  layers  of  pelvic  fascia.  These  do  not  meet  in 
the  middle  line,  and  the  space  is  continued  down  the  front 
of  the  prostate  to  the  triangular  ligament  and  membranous 
urethra. 

Etiology. — Pericystitis  may  be  secondary  to  disease  of  the 
bladder,  or  it  may  arise  in  neighbouring  organs  or  structures  ; 
rarely  it  is  idiopathic.  The  diseases  and  injuries  of  the  bladder 
which  most  commonly  give  rise  to  it  are  chronic  cystitis,  tubercu- 
lous cystitis,  malignant  growth,  diverticula,  •  and  perforation  of 
the  bladder  wall,  which  may  be  caused  by  mechanical  injury  with 
a  sound  or  lithotrite,  stabs  or  bullet  wounds,  fracture  of  the  pelvis, 
or  by  diseases  such  as  stone,  malignant  or  (rarely)  simple  ulcers. 
Men  are  more  often  affected  than  women,  owing  to  the  frequency 
of  obstructive  disease  in  the  male. 

Diseases  of  the  pelvic  organs  frequently  give  rise  to  peri- 
cystitis. Of  these  the  commonest  are  malignant  disease  or  ulcera- 
tion of  the  rectum,  inflanamation  of  the  seminal  vesicles,  uterus, 
and  Fallopian  tubes.  Appendical  abscesses  spread  into  the  pelvic 
areolar  tissue,  and  cause  acute  or  chronic  pericystitis. 

Suppuration  in  the  prevesical  areolar  tissue  or  abscess  of  the 
space  of  Retzius  forms  a  special  group  of  cases.  The  abscess 
may  follow  rupture  of  the  membranous  urethra,  or  tearing  of  the 
canal  with  septic  instruments  ;  infiltration  behind  a  stricture ; 
suprapubic  puncture  performed  with  a  septic  trocar,  or  followed 

517 


518  THE   BLADDER  [chap. 

by  leakage  of  septic  urine  from  the  bladder ;    or  necrosis  of  the 
pubic  bones. 

Pathology. — Two  forms  are  met  with,  similar  to  those  which 
occur  aromid  the  kidney,  namely,  (1)  chronic  fibro-lipomatous 
pericystitis,  with  or  without  points  of  suppuration,  and  (2)  peri- 
vesical suppuration  and  abscess. 

1.  In  the  fihro-lipomatous  type  a  mass  gradually  forms  around 
the  bladder,  confining  its  movements  and  forming  dense  adhesions 
to  the  peritoneum  and  surrounding  structures.  This  is  usually 
most  marked  around  the  base  of  the  bladder  and  around  the  lower 
ends  of  the  ureters  and  the  seminal  vesicles.  It  may  increase 
until  the  bladder  forms  a  small  cavity  surrounded  by  a  mass  of 
fibrous  tissue  and  coarse  fat  several  inches  in  thickness.  In  this, 
small  isolated  collections  of  pus  may  be  found.  In  such  cases 
there  is  advanced  disease  of  the  bladder,  "the  wall  of  which  is 
thick,  contracted,  and  fibrous.  In  cases  of  bygone  appendicitis 
the  perivesical  areolar  tissue  may  be  dense  and  fibrous. 

2.  Perivesical  suppuration  is  diffuse  or  circumscribed.  In  the 
diffuse  form  the  areolar  tissue  is  widely  infiltrated.  In  the  cir- 
cumscribed form  the  pus  is  thick  and  foul,  and  it  may  be  confined 
by  adhesions  to  the  anterior,  lateral,  or  posterior  aspect  of  the 
bladder. 

The  abscess  may  surround  a  diverticulum,  or  it  may  form  in 
the  outer  layers  of  the  bladder  wall. 

The  abscess  may  rupture  into  the  bladder  and  also  into  the 
rectum  or  peritoneum,  or,  after  forming  adhesions,  into  the  bowel, 
and  a  recto-  or  entero-vesical  fistula  results. 

Symptoms. — The  varying  etiology  and  position  of  the  peri- 
cystitis give  rise  to  a  variety  of  symptoms.  Clinically  the  cases 
may  be  divided  into  those  in  which  the  bladder  is  primarily  dis- 
eased and  those  in  which  there  is  disease  of  other  organs,  while 
the  prevesical  abscess  forms  a  special  group. 

1.  Pericystitis  following  disease  of  the  bladder.  — In 
the  course  of  chronic  cystitis  there  is  little  to  show  that  peri- 
cystitis is  present.  The  capacity  of  the  bladder  is  diminished,  and 
distension  becomes  impossible. 

On  rectal  examination,  and  especially  on  bimanual  palpation, 
the  greatly  thickened  bladder  wall  is  recognized.  When  the 
upper  part  of  the  bladder  is  affected  an  abdominal  tumour  may 
be  formed. 

Great  fibro-lipomatous  thickening  may  develop  around  a 
large  diverticulum,  which  can  be  felt  as  a  hard  mass  resembling 
a  malignant  growth.  In  these  cases  it  may  be  impossible  to  obtain 
a  good  cystoscopic  view  of  the  interior  of  the  bladder.     The  pre- 


XXXVIII]  PERIVESICAL  ABSCESS  519 

sence  and  size  of  the  diverticulum  may  be  demonstrated  by  obtain- 
ing a  radiogram  after  distension  of  the  bladder  with  bismuth 
emulsion  or  coUargol  solution. 

Localized  perivesical  suppuration  may  develop  insidiously, 
so  that  it  is  not  recognized  during  life. 

The  abscess  may  be  more  acute  and  may  rupture  into  the 
bladder  cavity,  giving  rise  to  an  attack  of  acute  cystitis  super- 
added to  the  symptoms  of  subacute  or  chronic  cystitis  which 
already  exist.  There  is  intense  pain  and  strangury,  the  urine  is 
alkaline,  purulent,  and  blood-stained.  Suprapubic  tenderness  and 
sometimes  distension  of  the  bowel  and  obstinate  constipation  are 
present.  The  temperature  is  high,  and  there  may  be  repeated 
rigors.  The  appetite  is  lost,  the  tongue  dry  and  glazed,  with 
intense  thirst  and  occasional  vomiting  and  rapid  wasting. 

The  case  may,  however,  pursue  a  much  milder  course.  A 
tumour  may  be  found  on  suprapubic  or  bimanual  palpation, 
which  may  be  mistaken  for  a  malignant  growth,  or  there  is  a 
boggy  mass  felt  in  the  rectum  at  the  bladder  base  or  to  one  or 
other  side  of  the  pelvis. 

Cystoscopy  is  often  impossible  owing  to  the  spasm  of  the 
bladder.  When  a  view  is  obtained  the  mucous  membrane  is  seen 
to  be  intensely  inflamed,  and  thrown  into  large,  irregular,  cede- 
matous  folds. 

Finally,  the  abscess  may  rupture  into  the  rectum  or  bowel, 
and  urine  is  discharged  with  the  faeces,  and  gas  and  fseculent 
urine  are  passed  by  the  urethra. 

2.  Prevesical  suppuration  or  abscess  of  the  space  of 
Retzius,  acute  or  chronic. — In  acute  cases  there  is  a  high, 
swinging  temperature,  often  with  repeated  rigors,  frequent  mic- 
turition and  strangury,  suprapubic  pain  and  tenderness,  and 
dullness  on  percussion.  A  prominent  rounded  swelling  appears 
above  the  pubes,  which  closely  resembles  the  contour  of  the  dis- 
tended bladder.  On  the  bladder  being  emptied  the  swelling  remains 
unchanged.  When  there  is  previous  disease  of  the  bladder  and 
urethra  the  urine  is  purulent,  and  may  be  alkaline  and  stinking. 

The  abscess  may  develop  more  slowly  and  insidiously.  In  a 
case  under  my  care  there  was  gradual  onset  of  increased  frequency 
and  pain  on  micturition,  vnth.  slightly  purulent  urine,  and  after 
some  weeks  cystoscopy  showed  a  prominent  patch  of  bullous 
cystitis  on  the  anterior  wall  of  the  bladder  closely  resembling  a 
growth.     This  rapidly  subsided  when  the  abscess  was  drained. 

3.  Pericystitis  following  disease  of  other  organs. — An 
appendicular  abscess  may  invade  the  areolar  tissue  of  the  pehas 
and  open  into  the  bladder.     During  the  course  of  an  attack  of 


520  THE  BLADDER  [chap. 

appendicitis  bladder  symptoms  appear.  Before  any  change  is 
observed  in  the  urine,  there  are  increased  frequency  of  micturi- 
tion, spasm  and  pain  on  passing  water,  and  the  mucous  mem- 
brane of  the  bladder  is  at  first  unchanged.  This  is  followed  by 
the  discharge  of  a  quantity  of  fetid  pus  in  the  urine  and  an  attack 
of  acute  cystitis,  and  a  fistula  may  form  between  the  appendix 
or  csecum  and  the  bladder. 

General  symptoms  are  prominent.  There  are  pain  in  the 
lower  part  of  the  abdomen,  high,  swinging  temperature,  and  rapid 
emaciation.  There  is  suprapubic  tenderness,  and  tenderness  on 
rectal  examination.  The  pain  is  not  affected  by  micturition,  but 
is  increased  by  movement.  The  urine  remains  clear  until  the 
abscess  has  ruptured  into  the  bladder,  when  it  becomes  purulent 
and  fetid ;  if  a  fistula  forms  it  contains  faecal  material,  and  gas  is 
passed  with  a  pecuUar  sensation  that  attracts  the  notice  of  the 
patient.  On  examination  there  is  a  hard  mass  in  the  region  of 
the  bladder,  which  may  fill  up  the  pelvis  and  extend  supra- 
pubically,  or  there  may  be  a  circumscribed  mass  in  the  pelvis 
in  close  relation  to  the  bladder.  On  rectal  examination  the  bladder 
base  is  tender,  thick,  and  boggy. 

The  cystoscope  shows  at  first  a  patch  of  cystitis  of  varying 
size,  and  later  oedema  and  intense  cystitis,  with  haemorrhages, 
and  finally  necrosis  at  some  point  of  the  wall,  giving  rise  to  a 
fistula.  Similar  symptoms  are  produced  by  pericystitis  originating 
in  the  rectum,  sigmoid  flexure,  or  small  intestine. 

Pyosalpinx  may  rupture  into  the  bladder,  but  this  termina- 
tion is  less  frequent  than  rupture  into  the  rectum  or  vagina. 
Gras  found  that  rupture  into  the  bladder  occurred  in  11  out  of 
60  cases.  The  bladder  may  remain  free  from  cystitis  for  a  long 
period,  even  when  pus  is  being  discharged  into  it  from  such  a 
collection.  After  rupture  of  the  abscess  the  cavity  may  heal  in 
a  few  days.  The  abscess  may  discharge  intermittently,  causing 
pain  and  fever  in  the  intervals  of  retention  of  pus,  or  there  may 
be  prolonged  discharge  of  pus  without  general  symptoms. 

The  diagnosis  is  made  by  the  intermittent  discharge  of  large 
quantities  of  pus  in  the  urine  and  the  absence  of  pyonephrosis. 
Cystoscopy  shows  a  patch  of  thickened  inflamed  mucous  mem- 
brane, and  a  round  or  irregular  opening  may  be  seen  in  this  area. 

Pericystitis  following  surgical  operations  or  resulting  from 
rupture  of  pelvic  organs  from  injury  tends  to  spread  widely  and 
rapidly.  There  are  repeated  rigors  and  high,  swinging  tempera- 
ture, and  the  patient  sinks  and  dies. 

Prognosis. — Spontaneous  recovery  after  rupture  of  an  abscess 
into  the  bladder  not  infrequently  takes  place.     In  cases  of  malignant 


XXXVIII]   PERIVESICAL  ABSCESS :  TREATMENT   521 

disease  or  tuberculous  cystitis  the  duration  of  life  is  shortened 
by  the  development  of  a  perivesical  abscess.  Pericystitis  follow- 
ing operations  upon  the  bladder  is  rapidly  fatal  in  many  cases. 
The  formation  of  a  recto-  or  entero-vesical  fistula  is  not  infrequent. 

Treatment. — No  radical  treatment  is  possible  for  chronic 
fibro-lipoinatous  cystitis.  The  application  of  heat  by  means  of 
fomentations,  Leiter's  tubes,  etc.,  has  been  followed  by  the  dis- 
appearance of  extensive  inflammatory  thickening  of  recent  origin. 

In  acute  cases  the  perivesical  areolar  planes  should  be  freely 
drained.  A  prevesical  abscess  should  be  incised  by  a  median 
suprapubic  incision,  large  rubber  drainage  tubes  introduced,  and 
the  cavity  freely  irrigated  daily.  In  some  cases  when  the  diagnosis 
is  obscure  the  perivesical  or  interstitial  abscess  is  opened  during 
an  exploration  of  the  bladder. 

Chronic  abscesses  are  surrounded  by  a  thick  wall  of  inflamma- 
tory tissue  which  mats  the  pelvic  organs  together  so  that  it  is 
impossible  to  distinguish  anatomical  structures.  The  incision 
should  be  suprapubic  and  vertical.  Occasionally  a  transverse 
incision  may  be  necessary,  and  rarely  the  abscess  is  drained  from 
the  perineum.  Great  care  should  be  taken  not  to  open  the  peri- 
toneum. When  pus  is  reached  by  careful  blunt  dissection,  the 
finger  is  introduced  and  the  opening  enlarged,  and  large  drainage 
tubes  are  inserted. 

LITERATURE 

Englisch,  Wieyi.  klin.  Woch.,  1889,  p.  25. 

Gras,  These  cle  Paris,   1905. 

MiiUer  et  Petitjean,   Gaz.  des  Hop.,  1908,  p.  819. 

Schmidt,  Surg.,   Gyn.,  and  ObsL,   1911,  p.  281. 

Waiko,  Munch,  med.  Woch.,  1904. 

Zuckerkandl,  Handhuch  der  Urologie  (von  Frisch  iind  Zuckerkandl),  1905,  B.  ii. 


CHAPTER  XXXIX 

FISTULA  OF  THE  BLADDER  AND  PERIVESICAL 
HYDATID    CYSTS 

SUPRAPUBIC  VESICAL  FISTULA 

The  orifice  of  the  fistula  is  usually  situated  at  the  lower  end  of 
a  suprapubic  operation  scar.  It  is  small,  and  a  bud  of  granula- 
tion tissue  may  project  from  it,  or  it  may  lie  at  the  bottom  of 
a  depressed  scar.  The  surrounding  skin  is  usually  healthy,  but  if 
the  urine  is  decomposing  and  constant  cleanliness  is  not  observed 
the  scar  is  thick  and  red,  and  the  skin  inflamed  and  excoriated. 
The  whole  of  the  urine  may  pass  this  way,  or  the  fistula  may  leak 
only  when  the  bladder  contracts,  the  urine  being  discharged  partly 
by  the  urethra  and  partly  by  the  fistula.  Sometimes  a  tiny  jet 
of  urine  is  discharged  from  the  fistula  for  some  distance  at  each 
micturition.     The  fistula  may  close  for  a  time  and  then  leak  again. 

Etiology. — A  permanent  fistula  may  be  intentionally  formed 
by  the  surgeon  for  incurable  urethral  obstruction  or  other  disease. 
Very  rarely  the  fistula  is  the  result  of  a  wound  of  the  bladder, 
unconnected  with  operation.  A  spontaneous  fistula  from  ex- 
tension of  disease  of  the  bladder,  such  as  malignant  growth  or 
tuberculous  disease,  is  rare.  The  scar  of  an  old  suprapubic  cyst- 
otomy wound  may  break  down  and  a  fistula  form  some  months 
or  years  after  the  operation. 

The  most  frequent  form  of  fistula  results  from  the  non-healing 
of  a  suprapubic  cystotomy  wound.  The  principal  causes  of  its 
persistence  are  mistakes  in  technique  and  sepsis,  but  other  factors 
may  be  present. 

Too  long  retention  of  drainage  tubes  in  a  cystotomy  wound 
causes  a  thick  hard  tube  of  fibrous  tissue  to  form,  which  prevents 
healing  by  granulation.  A  cystotomy  wound  which  lies  low  down 
in  the  anterior  wall  of  the  bladder  near  the  urethra  and  behind 
the  pubic  symphysis  heals  less  readily  than  a  wound  placed  high 
up  above  the  pubes.  The  bladder  wall  becomes  adherent  to  the 
posterior  surface  of  the  symphysis,  and  this  interferes  with  the 
healing  of  the  fistula. 

522 


CHAP.  XXXIX]         SUPRAPUBIC   FISTULA  523 

Prolapse  of  a  peritoneal  sac  between  the  muscles  of  the  abdo- 
minal wall  interferes  with  the  healing  of  the  suprapubic  wound. 
This  difficulty  is  most  frequently  encountered  after  the  transverse 
incision  from  cystotomy,  but  it  may  also  follow  a  vertical  incision. 
In  both  it  is  due  to  breaking  doN\ai  of  the  wound  from  sepsis,  or 
to  imperfect  technique  in  the  repair  of  the  abdominal  wall. 

The  spread  of  a  rapidly  growing  malignant  growth  of  the 
bladder  along  the  suprapubic  tract  and  tuberculous  infection  of 
the  wall  are  rare  causes  of  fistula.  Unrelieved  urethral  obstruc- 
tion caused  by  simple  or  malignant  enlargement  of  the  prostate 
or  stricture  results  in  the  formation  of  fistula  after  cystotomy. 
Cystitis  resulting  from  recurring  infection  from  a  congenital 
diverticulum  may  cause  a  persistent  fistula  after  cystotomy.  After^ 
theoperation  of  suprapubic  prostatectomy,  fistula  may  be  due  to 
sepsis  or  to  obstruction  resulting  from  incomplete  removal  oF 
the  enlarged  prostate,  stenosis  at  the  vesical  outlet,  stone  in  the 
prostaf! c '  "C a vrfvr'OT''the"recurrence  of  carcinoma  of  Ihe  prostate. 
DelaVed "healing  of  suprapubic  wounds  is  not  intrequenH^ODservM 
in  very  old  and  feeble  patients,  and  in  patients  suffering  from 
nervous  disease. 

Treatment. — Sepsis  must  be  energetically  treated  by  the 
administration  of  urinary  antiseptics  and  by  daily  washing  the 
bladder,  a  catheter  being  tied  in  the  urethra.  The  urine  should 
be  examined  bacteriologically,  and  a  vaccine  prepared  from  the 
predominant  organisms  and  given  in  increasing  doses. 

Should  these  measures  fail,  and  should  phosphatic  debris  or 
calculi  or  imrelieved  urethral  obstruction  be  present,  operation  is 
necessary.  The  track  of  the  suprapubic  fistula  should  be  dis- 
sected out  down  to  the  bladder  wall.  Care  is  taken  to  avoid 
opening  the  peritoneum,  which  is  frequently  adherent  to  the 
scar  or  may  form  a  pocket  in  it.  If  the  peritoneal  cavity  is 
opened  the  forefinger  should  be  introduced  and  used  as  a  guide 
to  dissect  the  peritoneum  up,  and  the  wound  should  then  be  closed 
with  catgut  and  the  operation  continued.  The  thick  mass  of  scar 
tissue  should  be  removed,  exposing  the  rectus  muscle  on  each  side, 
and  dissection  should  be  carried  down  behind  the  pubic  symphysis 
so  as  to  free  the  bladder  wall.  The  fistulous  track  is  removed 
and  the  bladder  cavity  explored  with  the  finger.  Phosphatic  debris 
or  stone  is  removed,  stenosis  at  the  neck  of  the  bladder  is  treated 
by  free  cutting  on  a  sound,  and  obstructing  portions  of  an  adeno- 
matous prostate  are  shelled  out.  Should  it  be  considered  ad\asable, 
the  wound  in  the  bladder  is  closed  with  one  or  two  rows  of  inter- 
rupted catgut  sutures,  a  small  drainage  tube  placed  in  the  lower 
end  of  the  abdominal  wound,  and  the  recti  muscles  and  sheaths 


524  THE   BLADDER  [chap. 

carefully  united  with  interrupted  catgut  sutures.     A  catheter  is 
tied  in  the  urethra  for  a  week. 

The  septic  state  of  the  bladder,  or  the  possibility  of  hsemorrhage, 
or  the  presence  of  symptoms  of  renal  disease  may  render  it  unwise 
to  close  the  wound  after  dissecting  out  the  fistula.  A  rubber  tube 
is  inserted,  and  the  bladder  treated  by  constant  irrigation  or  re- 
peated washing.  After  a  week  the  tube  is  removed  and  the 
wound  allowed  to  heal. 

VESICO-INTESTINAL  FISTULA 

Etiology. — The  fistula  may  be  spontaneous  or  traumatic. 
Spontaneous  fistula  may  take  origin  in  the  bladder  in  chronic 
cystitis,  malignant  growth,  or  some  other  condition  which  will 
cause  perivesical  abscess  {see  p.  517).  The  abscess  forms  adhesions 
to  the  rectum  or  intestine,  and  ruptures  both  into  this  and  the 
bladder. 

Barely,  tuberculosis  of  the  bladder  or  prostate  or  malignant 
growths  of  these  organs  is  the  cause  of  the  fistula. 

Simple,  tuberculous,  or  malignant  ulceration  of  the  rectum 
or  intestine  may  lead  to  adhesions  to  the  bladder  and  the  forma- 
tion of  a  fistula.  Pascal  found  the  following  order  of  frequency 
in  collected  cases  :  Malignant  growth  of  the  intestine  35  cases, 
tuberculosis  6,  syphilis  3,  actinomycosis  3.  Of  13  cases  of  faecal 
fistula  of  the  bladder  under  my  care  only  3  were  due  to  malig- 
nant growths,  1  at  the  ileo-csecal  valve  and  the  other  2  in  the 
sigmoid  flexure  and  rectum.  The  remaining  10  cases  were  due  to 
— abscess  round  the  bowel  of  unknown  origin  2,  stricture  and 
abscess  of  the  wall  of  the  sigmoid  flexure  following  dysentery  2, 
diverticulitis  and  abscess  round  the  sigmoid  flexure  1,  appendi- 
citis 1,  typhoid  fever  1,  perivesical  abscess  following  cystitis  1, 
non- tuberculous  prostatic  abscess  1,  diverticulum  of  the  bladder  1. 

Traumatic  fistula  follows  woimds  of  the  abdomen  or  perineum, 
the  opening  either  resulting  from  a  wound  or  from  subsequent 
suppuration  and  sloughing. 

Pathology. — The  opening  in  the  bladder  is  most  frequently 
found  on  the  posterior  wall,  high  up,  or  it  may  be  in  the  neigh- 
bourhood of  the  ureters.  Fistulse  are  less  often  found  in  other 
parts  of  the  bladder,  and  are  rarest  on  the  anterior  wall.  A  fistula 
on  the  right  side  of  the  bladder  usually  communicates  with  the 
caecum  or  the  appendix,  and  one  on  the  left  side  with  the  sigmoid, 
but  I  have  known  a  fistula  due  to  abscess  round  the  sigmoid  open 
on  the  right  side  of  the  bladder.  The  opening  may  be  so  small 
that  it  will  only  admit  a  probe,  or  it  may  be  the  size  of  a  sixpenny- 
piece.     It  is  surrounded  by  an  area  of  inflammation  of  varying 


XXXIX]  VESIGO-INTESTINAL   FISTULA  525 

intensity.  The  vesical  opening  may  enter  directly  into  the  bowel, 
but  there  is  usually  either  a  tortuous  track  or  an  intermediate 
cavity.  Earely  there  are  several  openings  into  the  bowel  or  into 
other  organs,  such  as  the  uterus,  and  only  one  into  the  bladder. 
The  following  is  the  order  in  which,  according  to  Pascal,  the 
different  parts  of  the  bowel  are  affected  :  Eectum,  57' 9  per  cent.  ; 
sigmoid  flexure,  21-5  per  cent.  ;  ileum,  13-3  per  cent.  ;  csecum, 
1  per  cent. 

The  coils  of  intestine  are  usually  matted  in  a  dense  mass, 
adherent  to  the  bladder  and  filling  the  pelvis,  and  there  may  be 
narrowing  of  the  bowel  and  dilatation  above  the  narrow  part. 
There  is  cystitis  to  a  varying  degree,  and  ascending  pyelonephritis 
is  the  cause  of  death  in  the  majority  of  cases. 

Symptoms. — When  the  fistula  forms  in  a  pre\'iously  healthy 
bladder  the  onset  is  frequently  insidious,  and  the  cause  of  the 
symptoms  at  first  obscure.  Spontaneous  cystitis  gradually  develops, 
and  persists  sometimes  for  some  weeks  before  a  fistula  is  actually 
formed.  I  have  cystoscoped  a  patient  at  this  stage,  and  found 
cystitis  distributed  over  the  posterior  wall  but  not  otherwise 
distinctive.  Obscure  abdominal  or  peh'ic  pain  may  be  present, 
and  occasionally  there  are  rigors,  high  temperature,  and  other 
symptoms  of  deep-seated  suppuration.  A  history  of  rectal  or 
intestinal  disease  may  be  given,  or  there  may  have  been  long- 
standing disease  of  the  bladder  when  the  primary  disease  is  in  this 
organ.  The  preliminary  stage  may  be  rupture  of  an  abscess  into 
the  bladder.  A  quantity  of  pus  is  discharged  in  the  urine,  and 
blood  may  also  be  present ;  rarely  there  is  a  sharp  attack  of 
hsematuria.     These  symptoms  may,  however,  be  absent. 

Pneimiaturia,  or  the  escape  of  gas  by  the  urethra,  is  a  constant 
and  characteristic  sign,  and  is  frequently  the  first  intimation  that 
perforation  has  occurred.  The  gas  is  usually  discharged  at  the 
end  of  micturition  with  a  bubbling  soimd  and  a  peculiar  sensation. 
It  may  appear  during  micturition,  or  may  only  be  present  when 
the  bowels  move.     Distension  of  the  bladder  with  gas  has  occurred. 

The  passage  of  fsecal  material  in  the  urine  may  be  constant 
or  intermittent.  There  are  only  a  few  brown  shreds,  or  irregular 
masses  of  brown  fsecal  matter  of  considerable  size  may  be  passed. 
The  condition  of  the  urine  is  characteristic.  "When  the  quantity 
of  faecal  matter  is  moderate,  the  urine  is  hazy  with  mucus  and 
bacteria,  and  contains  brown  shreds,  and  irregular  white  flakes  or 
semitransparent  shreds  of  meat  fibre.  There  may  be  a  distinct 
faecal  odour  or  only  a  faint  trace.  When  larger  quantities  are 
present  the  urine  may  resemble  weak  beef-tea ;  fragments  of 
undigested  food,  portions  of   grape-skin,  grape-seeds,  orange-pips, 


526  THE   BLADDER  [chap. 

fish-bones  or  fins,  etc.,  may  be  distinguisbed.  When  the  fistula  is 
connected  with  the  small  intestine  the  urine  is  yellow  with  bile. - 
The  reaction  of  the  urine  is  acid,  and  it  contains  albumin  and 
mucus  and  many  varieties  of  bacteria,  among  which  the  bacillus 
coli  predominates. 

When  the  escape  of  bowel  contents  into  the  bladder  is  inter- 
mittent, the  "  attacks "  occur  after  some  dietetic  indiscretion 
which  induces  diarrhoea. 

Frequent  micturition  is  present  and  is  due  to  cystitis.  There 
are  acute  exacerbations  and  periods  of  quiescence.  Urine  is  often 
passed  by  the  bowel,  the  quantity  varying  from  some  ounces  to 
the  entire  urinary  secretion.  Frequent  watery  stools  of  urine  and 
faecal  matter  are  passed,  or  if  constipation  is  present  the  urine  may 
be  discharged  from  the  rectum  with  little  faecal  matter.  The 
diarrhoea  varies  inversely  with  the  quantity  of  urine  passed  by 
the  urethra. 

Cystoscopy  may  be  very  difiicult  owing  to  the  irritable  condi- 
tion of  the  bladder,  but  in  some  cases  the  capacity  amounts  to  8  or 
12  oz.,  and  the  examination  is  easy.  The  opening  of  the  fistula 
is  frequently  hidden  behind  a  fold  or  ridge  of  mucous  membrane, 
and  cannot  be  seen.  In  an  old-standing  fistula  the  cystitis  is  often 
moderate,  and  may  be  confined  to  the  immediate  neighbourhood 
of  the  opening  The  orifice  of  the  fistula  may  be  a  small  round 
opening  level  with  the  general  surface,  with  a  plug  of  faecal  matter 
protruding  from  it,  or  it  may  be  surrounded  by  a  button  of  closely 
set  oedematous  "  bullae."  There  may  be  a  malignant  growth  in 
the  bladder,  surrounding  the  orifice. 

Course  and  prognosis. — The  condition  may  continue  for 
many  years  without  affecting  the  health  of  the  patient  unless  the 
original  disease  is  fatal.  I  have  seen  patients  in  good  health 
three,  four,  and  twenty  years  after  the  fistula  became  estabhshed. 

The  complications  which  may  supervene  are  recurrent  retention 
of  faecal  material  and  pus  in  an  intermediate  cavity,  peritonitis, 
ascending  pyelonephritis,  and  intestinal  obstruction. 

Diagnosis. — ^Pneumaturia  and  faecal  material  in  the  urine  are 
constant  and  characteristic.  It  may  be  impossible  to  distinguish 
between  fistula  resulting  from  malignant  growth  of  the  bowel  and 
that  produced  by  other  causes.  A  history  of  typhoid  fever,  dys- 
entery, or  other  probable  cause  of  ulceration  of  the  bowel  is  against 
malignant  growth,  while  the  presence  of  a  well-defined  hard  mass 
in  the  region  of  the  caecum  or  sigmoid  and  the  history  of  haemor- 
rhage from  the  bowel  and  of  the  early  onset  of  obstruction  are 
in  favour  of  a  malignant  growth.  A  mass  of  inflammatory  material 
with  matted  coils  of  intestine  in  a  case  of  non-malignant  disease 


XXXIX]  VESICO-INTESTINAL  FISTULA  527 

may  readily  be  mistaken  for  a  malignant  growth,  even  after  opening 
the  abdomen.  The  lower  bowel  should  be  examined  with  the 
proctoscope  and  sigmoidoscope.  It  may  be  very  difficult  to  ascer- 
tain the  position  of  the  mtestinal  orifice.  When  the  small  intestine 
is  affected,  the  yellow  biliary  colour  of  the  urine  is  characteristic. 

A  mass  in  the  right  iliac  fossa,  and  the  fistula  seen  by  the 
cystoscope  on  this  side  of  the  bladder,  will  point  to  the  caecum 
or  appendix,  and  these  signs  on  the  left  side  to  the  sigmoid.  If 
the  orifice  is  rectal,  the  diagnosis  can  usually  be  made  with  the 
finger  and  the  proctoscope,  aided  by  the  injection  of  coloured 
fluids  into  the  bladder. 

Treatment. — In  some  cases  washing  the  bladder  and  rectum 
and  careful  attention  to  diet  may  be  followed  by  closure  of  the 
fistula. 

Palliative  surgery. — A  short  circuit  may  be  made  so  that 
the  portion  of  bowel  is  excluded,  and  faecal  material  thus  prevented 
from  entering  the  fistula.  When  the  fistula  opens  into  the  rectum 
colotomy  may  be  performed.  A  patient  under  my  care  was  well 
and  comfortable  after  sixteen  years,  but  the  recto-vesical  fistula 
persisted. 

Radical  treatment  •  consists  in  attempting  to  close  the  fistula 
by  operation. .  This  has  been  performed  through  the  rectum  after 
dilatation  of  the  anal  sphincter,  with  some  successes,  and  a  few 
cases  have  been  operated  upon  through  a  suprapubic  cystotomy 
w^ound.  These  methods  are,  however,  inferior  to  the  perineal 
route  practised  by  Zuckerkandl.  A  transverse  pre-anal  incision 
is  made,  the  rectum  separated  from  the  prostate  and  bladder, 
the  fistulous  tract  cut  across,  and  the  openings  in  the  bladder 
and  rectum  are  closed.  The  bladder  and  rectum  are  kept  apart 
with  a  gauze  plug.  In  fistula  originating  above  the  rectum  the 
abdomen  is  opened  and  the  adherent  coils  of  intestine  are 
separated  until  the  portion  from  which  the  fistula  arises  is  identi- 
fied. A  part  of  this  is  excised  and  the  ends  are  anastomosed ;  or 
it  may  be  possible  to  close  the  openings  in  the  intestine  and  bladder 
without  resection  of  the  former. 

VESICO-VAGINAL  FISTULA 

Etiology. — Traumatic  vesico-vaginal  fistula  is  rare  apart 
from  surgical  operations  and  parturition.  In  operations  upon  the 
genital  organs  an  accidental  vesico-vaginal  fistula  may  be  pro- 
duced. In  order  to  drain  the  bladder  in  cystitis  a  temporary 
vaginal  fistula  is  sometimes  made,  and  this  may  resist  attempts  at 
closure  ;  or  the  opening  may  have  been  made  for  the  removal  of 
a  stone  in  the  bladder.     Injury  to  the  vaginal  wall  and  subsequent 


528  THE  BLADDER  [chap. 

formation  of  a  fistula  may  result  from  the  pressure  of  the  foetal 
head  or  of  instruments  during  parturition.  Foreign  bodies  in 
the  vagina,  such  as  a  pessary,  may  ulcerate  into  the  bladder. 
Spontaneous  fistula  may  form  from  the  ulceration  of  mahgnant 
growths  of  the  bladder  or  cervix  uteri,  or  from  ulceration  due 
to  tuberculosis  or  other  infection. 

Pathology. — The  common  form  opens  directly  from  the  base 
of  the  bladder  at  or  behind  the  trigone,  in  the  upper  part  of  the 
anterior  vaginal  wall.  Less  frequently  the  fistula  opens  into  the 
cervix  uteri.  The  ureter  may  be  implicated  when  extensive  de- 
struction has  occurred  in  prolonged  labour,  and  a  vesico-uretero- 
vaginal  fistula  results. 

In  large  fistulse  there  is  generally  some  prolapse  of  the  vesical 
mucous  membrane  into  the  vagina. 

There  is  usually  much  scarring  around  the  fistula,  and  if  the 
fistula  has  followed  a  vaginal  hysterectomy  the  upper  part  of 
the  vagina  is  rigid  and  fixed. 

The  vagina  is  irritated  by  the  urine,  especially  when  it  is  de- 
composing, and  the  vulva  and  upper  part  of  the  thighs  are  excori- 
ated.    There  is  cystitis,  and  frequently  stone  in  the  bladder. 

Symptoms. — The  escape  of  urine  from  the  vagina  is  the  only 
symptom.  This  will  vary  according  to  the  size  of  the  fistula. 
The  whole  of  the  urine  may  escape  day  and  night,  or  only  a  part 
of  it,  and  sometimes  it  only  escapes  when  the  patient  walks  and 
is  retained  when  she  is  recumbent.  The  urine  is  alkaline  and 
decomposing,  and  a  urinary  odour  surrounds  the  patient. 

Diagnosis. — Vesico-vaginal  fistula  is  recognized  by  examina- 
tion with  a  vaginal  speculum.  In  vesico-uterine  fistula  urine  can 
be  seen  trickling  from  the  os  uteri,  and  injection  of  coloured  fluid 
into  the  bladder  is  followed  by  its  appearance  at  the  os. 

In  vesico-uretero-vaginal  fistula  there  is  widespread  destruc- 
tion, and  the  position  of  the  ureteric  orifices  will  be  distinguished 
after  careful  examination  aided  by  the  intramuscular  injection  of 
methylene  blue  or  indigo  carmine. 

Prognosis. — If  the  fistula  does  not  close  in  a  few  weeks  after 
the  injury  it  is  unlikely  that  it  will  heal  spontaneously.  The 
chief  danger  is  ascending  pyelonephritis,  but,  apart  from  this, 
unless  the  fistula  is  cured  the  patient  must  become  a  recluse, 
and  sometimes  is  bedridden. 

Treatment.^ — This  consists  in  plastic  operation,  but  before  it 
is  undertaken  the  urine  must,  if  possible,  be  rendered  aseptic  by 
urinary  antiseptics  and  by  washing  the  bladder.  Calculi  must 
be  searched  for  and  removed,  and  inflammation  of  the  vagina  and 
vulva  treated  by  soothing  douches  and  lotions.     Free  drainage 


XXXIX]  VESIGO-VAGINAL  FISTULA  529 

of  the  urine  by  suprapubic  cystotomy  should  be  established  for 
at  least  a  week  before  all  these  plastic  operations.  At  the  opera- 
tion free  access  to  the  fistula  must  be  obtained,  and  if  the  vagina 
is  scarred  and  narrowed  a  preliminary  plastic  operation  may  be 
necessary.  The  ureters  should  be  properly  safeguarded  by  passing 
a  catheter  along  each  at  the  commencement  of  the  operation. 

There  are  three  methods  of  approach — (1)  vaginal,  (2)  vesical, 
(3)  peritoneal.  The  vaginal  method  is  that  which  is  most  fre- 
quently employed.  A  number  of  operations  have  been  used,  and 
for  these  special  works  should  be  consulted.  The  author  makes 
use  of  Young's  prostatic  retractor,  introduced  from  the  vagina 
through  the  fistula,  in  order  to  pull  do^vn  and  steady  the  fistula 
during  the  operation,  and  dissects  up  large  anterior  and  posterior 
flaps  of  the  vaginal  wall,  which  are  brought  together  after  excision 
of  the  track.  Whatever  method  is  used,  the  bladder  and  vagina 
should  be  dissected  very  freely  from  each  other,  and  if  the  cervix 
of  the  uterus  is  involved  this  should  be  freed.  The  free  edges 
of  the  bladder  and  then  those  of  the  vagina  should  be  accurately 
sutured.  A  plug  of  antiseptic  gauze  should  be  placed  in  the 
vagina  to  keep  the  surfaces  of  the  flaps  in  apposition,  and  should 
be  changed  daily.  A  -White's  suction  apparatus  is  fitted  to  the 
suprapubic  wound  to  keep  the  bladder  dry.  The  vagina  and 
bladder  are  flushed  out  daily.  At  the  end  of  a  week  the  tubes 
are  removed  and  the  suprapubic  wound  is  allowed  to  heal. 

I  have  found  a  combined  vesical  and  vaginal  operation  useful. 
The  bladder  is  opened  suprapubically  with  the  patient  in  the 
Trendelenburg  position,  and  the  bladder  wall  round  the  fistula 
freed  and  sutured.  The  patient  is  then  placed  in  the  lithotomy 
position  and  the  vaginal  aspect  of  the  fistula  treated  in  the  same 
way.     Postoperative  suprapubic  drainage  is  essential. 

LITERATURE 

Bishop,  Lancet,  1897,  i.  1675. 

Legueu,   Traite  Ghirurgical  d'  Urologie.     1910. 

Pascal,  These  de  Paris,  1899. 

Walker,  Thomson,  Burghard's  System  of  Operative  Surgery,  iii.  481. 

PEEIVESICAL  HYDATID  CYSTS 

These  are  situated  in  the  subperitoneal  tissue  of  the  pelvis, 
and  may  be  primary  or  secondary.  The  primary  cysts  are  very 
rare,  only  a  few  examples  having  been  recorded.  Secondary  cysts 
are  more  common,  the  primary  hydatid  cyst  being  in  the  liver 
or  elsewhere  in  the  abdominal  cavity.  It  has  been  proved  by 
experiment  that  when  scolices  are  introduced  into  the  peritoneal 
2i 


530  THE   BLADDER  [chap,  xxxix 

cavity  they  may  penetrate  the  peritoneum,   and  hydatid  cysts 
develop  in  the  subperitoneal  tissue  of  the  pelvis. 

The  cyst  forms  in  the  subperitoneal  tissue  of  the  recto-vesical 
pouch,  and  becomes  adherent  to  the  bladder,  prostate,  and  rec- 
tum. As  it  develops  it  mounts  above  the  brim  of  the  pelvis  and 
grows  into  a  cyst  the  size  of  a  child's  head  or  larger.  It  is  usually 
single.  The  peritoneum  is  stretched  over  it  and  adherent  to 
the  cyst  wall.  Pressure  upon  the  ureters  in  the  pelvis  may  cause 
obstruction  and  dilatation. 

Symptoms. — Frequent  micturition  and  pain  in  the  pelvis 
and  on  micturition  are  the  earliest  symptoms.  Sciatica  has  been 
observed.  Eetention  of  urine  occurs  later  from  prostatic  obstruc- 
tion. A  swelling  appears  above  the  pubes,  which  is  firm,  rounded, 
and  dull  on  percussion,  and  closely  resembles  a  distended  bladder. 
In  a  case  that  came  under  my  observation  there  were  difficult 
micturition  and  a  large,  globular  suprapubic  swelling  in  a  young 
man.  The  swelling  was  looked  upon  as  due  to  a  distended 
bladder,  but  on  passage  of  a  catheter  the  tumour  remained  after 
the  bladder  was  emptied. 

On  rectal  examination  a  tense  swelling  is  felt  in  the  region 
of  the  recto-vesical  pouch,  and  bimanually  fluctuation  can  be 
detected  between  the  rectal  finger  and  the  hand  above  the  pubes. 

Hydatid  fremitus  is  rarely  detected.  Rectal  obstruction  may 
be  produced  by  a  large  cyst,  and  the  ureters  become  dilated  by 
pressure  in  the  pelvis. 

Diagnosis. — The  diagnosis  is  not  likely  to  be  made  before  a 
suprapubic  swelling  has  appeared.  Previous  to  this,  malignant 
growth  of  the  prostate  or  pericystitis  is  the  condition  for  which 
it  will  probably  be  mistaken.  The  presence  of  a  fluctuating  cyst 
in  the  male,  in  close  relation  to  the  bladder  and  unaflected  by 
distension  of  the  bladder,  with  no  opening  of  a  diverticulum  in  the 
bladder,  should  raise  a  strong  suspicion  of  hydatid  cyst. 

The  reaction  known  as  "  fixation  of  the  complement "  has 
given  important  results,  and  a  diagnosis  of  hydatid  cyst  can  be 
made  by  this  means. 

Treatment." — The  cyst  is  exposed  by  a  vertical  median  supra- 
pubic incision,  and  the  contents  removed.  If  the  cavity  is  septic 
it  should  be  drained  by  large  tubes  or  by  stitching  the  edges  of 
the  sac  to  the  skin.  If  sepsis  is  not  present  the  cavity  should 
be  closed. 

LITERATURE 

Cranwell  and  VegOS,   Rev.  de  la  Soc.  Med.  Argentina,  1S04,  xii.  215. 
Frustemberg,  ^wn.  d.  Mai.  d.  Org.   Gen.-Urin.,  1901,  p.  1160. 
Kaliontzis,  ^wn.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1909,  p.  397. 
Legueu,  IIP  Sess.  de  I'Assoc.  Franc.  d'Urol.,  Paris,  1899,  p.  312, 


CHAPTER  XL 
NERVOUS  DISEASES  OF  THE  BLADDER 

The  nervous  diseases  which  afiect  the  bladder  are  principally 
spinal  lesions.  Cerebral  disease  rarely  affects  the  organ  so  long 
as  consciousness  is  retained,  and  it  is  doubtful  if  it  is  afiected  by 
changes  in  the  peripheral  nerves. 

Symptoms. — Nervous  disease  of  the  bladder  gives  rise  to 
pain,  increased  desire,  diminished  desire,  difficulty,  retention, 
incontinence. 

1.  Pain. — There  is  occasionally  aching  pain  in  the  bladder. 
This  is  constant,  capricious,  and  unaffected  by  micturition.  In 
tabes  attacks  of  acute  pain  (vesical  crises)  are  sometimes  observed. 

2.  Increased  desire  and  bladder  spasm  (hypertonic  blad- 
der).— Increased  frequency  may  be  the  only  symptom  of  nervous 
disease  of  the  bladder,  or  it  may  be  one  of  a  group  of  symptoms. 
It  is  not  seldom  combined  with  partial  retention.  In  rare  cases 
bladder  spasm  is  present.  There  is  increase  in  frequency,  and 
the  bladder  expels  the  urine  forcibly  when  a  small  quantity  has 
collected.  On  introduction  of  a  catheter  and  injection  of  fluid 
into  the  bladder  the  fluid  is  expelled  with  force,  and  the  catheter 
may  also  be  ejected.  This  form  of  irritability  leads  to  an  active 
incontinence.  I  have  met  with  the  symptom  in  cases  of  multiple 
sclerosis. 

Frankl-Hochwart  and  Zuckerkandl  found  the  intravesical 
tension  in  such  cases  (hypertonic)  excessively  high  (80  cm.  water). 

3.  Diminished  desire. — The  patient  may  pass  urine  twice  in 
twenty-four  hours,  and  then  only  because  he  considers  it  neces- 
sary, not  from  the  sensation  of  desire  to  micturate.  With  this 
there  is  residual  urine  in  varying  amount. 

The  absence  of  desire  is  usually  combined  with  a  diminished 
sensibility  of  the  bladder  which  may  affect  the  mucous  membrane 
over  the  whole  surface  or  sometimes  over  half  of  the  organ.  The 
prostatic  urethra  may  retain  its  sensibility.  The  condition  is 
most  frequently  observed  in  tabes,  but  may  also  occur  in  trans- 
verse myelitis,  syringo-myelia,  diseases  of  the  cauda  equina,  spinal 
meningitis,  etc. 

531 


532  THE   BLADDER  [chap. 

4.  Difficult  micturition. — ^Micturition  is  difficult  in  almost  all 
cases  of  nervous  disease  of  the  bladder  from  spinal  lesions.  There 
is  delay  in  commencing,  and  the  patient  waits  a  few  seconds  to 
two  or  more  minutes  before  the  flow  appears.  The  stream  is 
poor,  it  drops  vertically  from  the  meatus,  and  may  be  merely  a 
dribble.  By  straining  with  the  abdominal  muscles,  and  some- 
times by  pressure  with  the  hand  above  the  pubes,  the  stream 
increases,  but  falls  away  again  into  a  final  dribble.  Intermission 
of  the  flow  is  frequently  observed.  Sometimes  the  patient  can 
only  pass  urine  when  at  stool,  or  by  assuming  some  peculiar 
position. 

An  early  symptom  may  be  the  inability  to  interrupt  the  stream 
during  the  flow.  The  patient  is  usually  aware  that  the  bladder 
has  not  been  completely  emptied.  The  cause  of  the  difficult  mic- 
turition is  paresis  of  the  bladder  muscle.  Frankl-Hochwart  men- 
tions spasm  of  .the  vesical  sphincter  as  an  additional  cause  occurring 
in  multiple  sclerosis  and  other  spinal  diseases,  but  he  admits  that 
it  is.  often  diagnosed  in  error.  In  paresis  of  the  bladder  there  is 
a  varying  quantity  of  residual  urine,  of  which  the  patient  may  be 
unconscious.  Tabes  is  the  most  frequent  cause,  but  other  spinal 
diseases  such  as  transverse  myelitis,  multiple  sclerosis,  and  syringo- 
myelia may  produce  it.  In  many  of  these  cases  the  nerve 
symptoms  are  slight  and  are  overlooked,  and  the  patient  is  treated 
for  stricture  or  other  urethral  obstruction — a  diagnosis  which  may 
appear  to  be  confirmed  by  some  difficulty  in  entering  the  mem- 
branous urethra  with  a  sound.  The  slack  urethral  muscles  in  these 
cases  allow  the  bulbous  urethra  to  sag  downwards  when  the  patient 
lies  on  his  back,  so  that  the  point  of  the  instrmnent  drops  past 
the  opening.  For  some  days  after  the  passage  of  a  large  instru- 
ment micturition  may  be  more  easily  performed,  and  this  may 
further  lead  the  surgeon  astray.  Paresis  is  said  to  result  from  pro- 
longed active  retention  of  urine  in  a  normal  individual.  After 
forcibly  retaining  the  urine  for  many  hours  the  patient  is  imable 
to  pass  urine.  Cases  where  permanent  paresis  has  followed  have 
been  recorded. 

5.  Complete  retention  (atonic  bladder). — ^Nervous  retention 
is  due  to  paralysis  of  the  bladder  muscle.  There  may  be  com- 
plete retention  when  the  bladder  is  first  aflected,  and,  later, 
improvement  takes  place  and  urine  is  passed  but  the  bladder 
is  incompletely  emptied.  Periods  of  complete  retention  lasting 
several  years  may  alternate  with  periods  of  partial  retention 
(difficult  micturition  with  residual  urine). 

6.  Incontinence  of  urine. — The  following  varieties  of  incon- 
tinence are  observed  in  nervous  diseases  : — 


XL]  NERVOUS   DISEASES  OF  BLADDER         r.33 

i.  Active  incontinence. 

(a)  Keflex  micturition. 

(b)  Incomplete  reflex  micturition, 
ii.  Passive  incontinence. 

(a)  Distension  with  overflow. 
(6)  Collapse  with  outflow. 

When  the  bladder  is  cut  oft"  from  the  control  of  the  cerebrum 
it  acts  automatically.  A  quantity  of  urine  collects,  the  reflex 
of  micturition  is  initiated,  and  the  bladder  empties  itself.  This 
is  repeated  at  intervals.  The  bladder  is  here  in  the  state  which 
is  normal  in  the  infant.  This  is  observed  in  lesions  above  the 
lumbar  centre,  and,  as  Mliller  has  shown,  in  lesions  involving  the 
lumbar  centre  also.  There  is  sometimes  uncontrollable  spasm  of 
the  bladder,  which  empties  itself  forcibly  whenever  a  small  quantity 
of  urine  collects  (hypertonic). 

In  many  cases,  in  addition  to  being  cut  oft  from  control,  the 
bladder  muscle  is  partly  paralysed,  either  temporarily  from  over- 
distension, or  permanently  from  disease  of  the  lumbar  or  sym- 
pathetic centres,  and  here  the  organ  is  distended  and  small 
quantities  of  urine  are  discharged  involuntarily  from  time  to 
time.  This  state  is  likely  to  be  mistaken  for  distension  with 
overflow  unless  careful  observations  are  made. 

The  bladder  may  only  be  partly  distended,  and  the  reflex 
micturition  leaves  behind  a  residuum  of  8  or  10  oz. 

In  passive  incontinence  the  contraction  of  the  bladder  is 
abolished  and  the  outflow  is  purely  mechanical. 

In  one  type  of  nervous  incontinence  the  bladder  is  fully  dis- 
tended and  the  surplus  urine  dribbles  away  continuously.  Here 
the  vesical  sphincter  is  still  active.  In  a  second  form  there  is 
no  distension  of  the  bladder,  both  the  detrusor  and  the  sphincter 
being  paralysed  and  the  urine  dribbling  away.  As  Corner  points 
out,  the  bladder  is  seldom  if  ever  empty,  even  where  both  detrusor 
and  sphincter  are  paralysed.  A  certain  amount  of  urine  collects 
before  the  pressure  is  sufficient  to  overcome  the  elastic  resistance 
of  the  urethra. 

Changes  in  the  bladder  in  nervous  disease. — Cystitis  is 
the  most  frequent  complication  in  paresis  of  the  bladder.  The 
infection  is  usually  introduced  by  the  catheter,  but  it  occasion- 
ally occurs  spontaneously,  bacteria  reaching  the  bladder  either 
through  the  urethra  or  after  excretion  by  the  kidneys.  With  the 
advent  of  cystitis  there  is  increased  frequency  of  micturition  and 
increased  sensibility  of  the  bladder  mucous  membrane  in  cases 
where  anaesthesia  of  the  bladder  has  been  a  prominent  symptom. 
The  quantity  of  residual  urine  is  usually  much  reduced.     Some- 


534  THE   BLADDER  [chap. 

times  there  is  painful  desire  to  micturate  with  inability  to  expel 
the  urine. 

Cystitis  becomes  chronic  in  the  majority  of  cases,  and  the 
urine  may  be  alkaline  and  ammoniacal.  Phosphatic  calculi  form 
rapidly. 

Trabeculation  in  the  early  stages  of  tabes  dorsalis  was  first 
observed  cystoscopically  by  Nitze,  while  Orth  and  others  have 
described  the  conditions  post  mortem  in  old-standing  cases  of 
tabes.  Bohme  described  8  cases  of  tabes  in  the  early  stage  when 
trabeculation  was  present,  and  he  regards  this  condition  of  the 
bladder  as  a  diagnostic  sign  of  tabes  in  the  earliest  stage.  I  have 
examined  (1911)  the  bladder  cystoscopically  in  31  cases  of  tabes  in 
its  early  and  irregular  forms.  (Plate  38,  Fig.  3-.)  Trabeculation 
was  generally  present,  but  was  occasionally  absent.  Trabecula- 
tion in  nervous  disease  is  most  frequently  found  in  tabes,  but  it 
is  not  confined  to  that  disease.  I  have  seen  it  in  atony  from 
postero-lateral  sclerosis  and  from  spina  bifida.  It  was  absent  in 
cases  of  multiple  sclerosis  and  supralumbar  myelitis  that  I  ex- 
amined. I  have  also  described  trabeculation  in  atony  without 
nervous  disease  or  urethral  obstruction. 

The  trabeculation  found  in  obstruction  differs  in  several 
particulars  from  that  found  in  spinal  disease. 

The  trabeculation  of  an  obstructed  bladder  is  coarse,  the 
muscular  ridges  being  thick  and  irregularly  branching,  the  inter- 
spaces deeply  pouched,  and  the  openings  of  the  saccules  often 
narrow.  In  trabeculation  without  gross  obstruction  the  muscle 
ridges  are  fine  and  evenly  set,  and  the  branching  is  regular  and 
orderly.  Very  fine  twigs  can  frequently  be  seen  branching  and 
interlacing.  A  solitary  muscle  band  may  stand  up  sharply  for 
°2  or  3  in.  on  the  bladder  wall.  The  interspaces  are  not  so  deep 
and  are  saucer-shaped. 

In  the  obstructed  bladder  the  whole  organ  is  affected,  the 
trigone  is  broken  up  into  hypertrophied  ridges  among  which  the 
ureteric  bar  is  hidden,  and  the  ureteric  orifices  are  difficult  to 
find.  In  the  unobstructed  trabeculated  bladder  the  side  walls 
and  apex  are  affected  while  the  trigone  escapes. 

Frankl-Hochwart  and  Bohme  believe  that  the  trabeculation 
is  due  to  hypertrophy  caused  by  obstruction,  which  they  state 
results  from  inability  of  the  sphincter  to  relax.  I  hold  that  the 
earliest  change  in  these  cases  is  atrophy,  and  that  the  prominence 
of  some  muscle  bundles  is  largely  due  to  atrophy  of  neighbouring 
bundles.  There  may  be  compensatory  hypertrophy  of  some  of 
the  remaining  bundles,  but  it  is  insufficient  to  replace  those  that 
have  atrophied. 


XL]  NERVOUS    DISEASES   OF  BLADDER  535 

Rarely  in  spinal  disease  ulceration  of  the  bladder  may  develop 
and  rapidly  perforate.  Such  cases  have  been  described  by  Hertig, 
le  Fur,  Posner,  and  others. 

Bladder   symptoms  in  special   nervous   diseases. — The 

bladder  is  more  often  affected  in  tabes  dorsal  is  than  in  other 
forms  of  nervous  disease.  The  type  which  most  frequently  comes 
under  the  observation  of  the  surgeon  is  an  irregular  form  when 
the  bladder  is  early  affected  while  the  symptoms  of  spinal  disease 
are  only  partly  developed. 

There  is  gradually  increasing  difficulty  in  micturition,  delay 
in  commencing  the  act,  a  loss  of  power  of  projection  so  that  the 
stream  tends  to  fall  more  vertically,  intermittent  flow  with  pauses 
of  varying  length,  and  dribbling  after  the  act  appears  to  be  com- 
pleted. There  is  not  infrequently  a  diminished  desire,  so  that 
the  patient  passes  water  less  often  than  usual,  and  this  only  from 
habit,  not  from  a  natural  call  to  micturate.  If  the  patient  is 
examined  at  tliis  time  there  will  be  found  a  varying  quantity  of 
residual  urine  (6-12  oz.),  with  widespread  trabeculation  of  the 
bladder.  The  tabetic  symptoms  may  be  confined  to  "  rheumatic  " 
pains  in  the  legs  and  modification  of  the  patellar  reflex,  or  the 
presence  of  Argyll-Robertson  pupils.  The  atony  of  the  bladder 
gradually  increases  until  there  is  complete  retention  of  mine,  or 
a  sudden  attack  of  retention  may  be  the  first  symptom  of  which 
the  patient  complains.  The  bladder  is  greatly  distended,  and 
there  is  incontinence  from  overflow,  or  the  patient  may  be  able 
to  expel  some  urine  voluntarily  by  contraction  of  the  abdominal 
muscles  or  pressure  with  his  hand.  Nocturnal  enuresis  is  usually 
present,  and  this  may  be  the  first  symptom. 

The  patient  may  feel  the  urine  escape,  but  frequently  the 
urethra  is  anaesthetic  and  the  first  feeling  is  one  of  dampness  of 
the  linen. 

After  a  period  varying  from  weeks  to  months  some  improve- 
ment in  the  tone  of  the  bladder  may  take  place,  the  residual 
urine  being  reduced  to  from  8  to  10  or  12  oz.  and  the  bladder 
remaining  in  this  condition. 

I  have  not  met  with  a  spasmodic  bladder  (h}^3ertomc)  in  tabes. 
Vesical  and  urethral  crises  are  rare.  Sudden  pain  is  felt  at  the 
neck  of  the  bladder,  or  along  the  urethra,  or  at  the  external  meatus, 
and  this  may  be  accompanied  by  intense  and  frequent  desire  to 
micturate  when  the  bladder  is  empty.  The  attacks  may  recur 
several  times  in  an  hour,  and  last  one  or  several  days. 

In  acute  and  chronic  spinal  meningitis,  and  acute  and 
chronic  myelitis,  and  in  multiple  sclerosis,  there  may  be 
initial  increased  frequency  of  micturition,  but  the  characteristic 


536  THE   BLADDER  [chap. 

change  in  the  bladder  is  gradually  increasing  atony,  and  com- 
plete retention  develops.  There  may  be  difiiculty  in  passing  a 
catheter,  from  spasm  of  the  sphincter.  Dribbling  of  urine  from 
over-distension  follows.  The  complete  retention  may  continue, 
but  usually  after  a  time  the  bladder  is  emptied  automatically. 
Spasmodic  contraction  of  the  bladder  (hypertonic)  is  occasionally 
observed.  When  this  is  present  it  usually  subsides  gradually, 
and  is  succeeded  by  reflex  micturition  or  atony. 

In  acute  and  chronic  anterior    poliomyelitis,    Friedreich's 
disease,   and  amyotrophic  sclerosis  the  bladder  is  unaffected. 

I'""     '      ■         ^  ^'    '"■"      ' 


Fig.  160. — Spina  bifida  of  sacrum,  with  atony  of  bladder. 

In  cerebral  disease  unassociated  with  loss  of  consciousness 
or  spinal  disease  the  bladder  may  be  aflected.  These  are  cases 
of  lesions  of  the  corpus  striatum  or  cortex,  and  possibly  of  the 
optic  thalamus  or  cerebellum. 

The  bladder  is  rarely  affected  in  polyneuritis. 

In  a  case  of  spina' bifida  affecting  the  sacral  canal  in  a  man 
aged  38  (Fig.  160)  there  was  difficult  micturition  and  a  poor  stream 
from  infancy.  At  the  age  of  19  complete  retention  developed,  and 
the  patient  became  dependent  upon  the  catheter  for  ten  or  twelve 
years,  with  intervals  of  a  few  days  at  a  time.  After  that  he  gave 
up  using  the  catheter  and  passed  water  with  dij6S.culty  for  seven 
years.    For  three  weeks  he  was  again  dependent  on  the  catheter. 


XL]         IDIOPATHIC  ATONY  OF   BLADDER         537 

There  was  loss  of  desire  and  an  absence  of  feeling  of  distension 
when  the  bladder  was  full.  He  also  suffered  from  weakness  of  the 
anal  sphincter,  and  a  loose  motion  could  not  be  retained. 

Atony  of  the  bladder  without  obstruction  or  signs 
of  nervous  disease. — I  have  described  a  series  of  cases  under 
this  title.  The  condition  frequently  occurred  in  patients  under 
30  years  (22,  22,  23,  28,  30),  and  a  history  of  syphilis  could  only 
be  obtained  in  two  cases.  There  were  gradual  onset  and  increase 
of  difficulty  in  micturition,  delay  in  initiation  of  the  act,  a  feeble, 
often  intermittent  stream.  Chronic  distension  of  the  bladder 
was  present  in  four  cases.  The  power  of  voluntary  micturition 
remained,  although  greatly  impaired.  In  the  remaining  cases 
there  was  residual  urine  varying  from  4  to  10  oz.  in  amount. 

Incontinence  of  urine  was  present  in  two  cases,  amounting 
in  one  to  the  escape  of  some  urine  on  coughing  or  sneezing,  and 
in  another  to  nocturnal  dribbling  from  an  over-distended  bladder. 

There  was  loss  of  sensation  in  the  bladder  with  reduced  fre- 
quency of  micturition  in  all  but  three  cases,  in  which  there  was 
increased  frequency  without  cystitis. 

Well-marked  trabeculation  of  the  bladder  wall  was  found  in  all. 

In  these  cases  there  was  atony  of  the  bladder  muscle  to  a 
varying  degree,  while  the  sphincter  was  weak  but  not  paralysed 
in  two  cases,  and  active  in  all  the  others. 

Urethral  obstruction  and  spinal  disease  were  eliminated.  The 
lesion  in  these  cases  was  probably  in  the  lowest  reflex  centres 
of  the  bladder,  namely,  the  hypogastric  and  haemorrhoidal  plexuses 
of  the  sympathetic. 

In  9  cases  there  had  been  atony  of  the  bladder  for  two,  two 
and  a  half,  four,  five,  six,  eight,  twelve,  fourteen,  and  eighteen 
years  respectively,  without  development  of  symptoms  of  spinal 
disease. 

The  absence  of  any  evidence  of  spinal  disease  on  examination 
of  the  cerebrc-spinal  fluid  obtained  by  lumbar  puncture  (by  Dr. 
Purves  Stewart),  and  the  long  duration  of  the  bladder  atony 
without  development  of  other  symptoms,  exclude  the  possibility 
of  the  atony  being  an  early  symptom  of  tabes. 

It  is  possible  that  a  lesion  localized  in  the  spinal  reflex  centre 
of  the  bladder  might  be  the  cause  of  this  atony,  but  why  such  a 
lesion  should  remain  confined  to  the  bladder  centre  in  all  these 
cases  is  difficult  of  explanation. 

Blum  and,  later,  Hahn  have  recorded  cases  of  injury  to  the 
nervous  system  from  falls  or  crushes,  where  permanent  injury 
to  the  spinal  bladder  centre  remained  after  the  immediate  results 
had  passed  off. 


538  THE   BLADDER  [chap. 

Injury  to  the  nervous  system. — Corner  has  investigated 
the  state  of  the  bladder  in  cases  of  injury  to  the  nervous  system. 
The  following  tables  are  extracted  from  his  admirable  article : — 
Concussion  of  the  hrain. 

1.  Keflex  or  unconscious  micturition. 

2.  Active  retention. 

{a)  Active  overflow. 

(b)  Passive  overflow. 

(c)  Absolute  retention. 

There  is  first  retention  of  urine,  which,  if  unrelieved,  may 
proceed  to  active  overflow  (reflex  contractions  expel  the  surplus 
urine  while  the  bladder  remains  distended),  or  to  passive  overflow 
(constant  dribbling  of  overflow  without  reflex  contractions),  or, 
if  urethral  obstruction  be  present,  absolute  retention  remains. 
Compression. 

1.  Passive  retention. 

2.  Active  paralytic  overflow. 

3.  Passive  paralytic  overflow. 

The  symptoms  differ  from  concussion  in  that  they  grow  pro- 
gressively more  severe.  In  the  later  stages  there  is  a  paralytic 
condition  of  the  bladder,  in  which  a  little  urine  collects,  although 
the  sphincter  is  also  paralysed,  and  at  first  the  escape  is  due  to 
contractions  of  the  bladder  which  are  entirely  local,  but  later 
these  are  lost  and  the  urine  dribbles  away. 
Spinal  injuries. 

1.  Supralumbar  lesions. 

(a)  Active  retention  and  its  possible  sequels. 

(b)  Keflex  micturition. 

(c)  Exaggerated  reflex  micturition. 

2.  Lumbar  lesion  (the  same  as  compression). 

{a)  Passive  retention  and  its  possible  sequels, 

(6)  Active  paralytic  overflow. 

(c)  Passive  overflow. 
Treatment  of  nervous  diseases  of  the  bladder.  L — Re- 
lief of  retention  and  residual  urine. — The  greatest  care 
must  be  exercised  in  all  instrumental  interference  to  avoid  intro- 
ducing bacteria  into  the  bladder.  For  complete  retention  catheter 
life  is  necessary.  The  catheter  should  be  passed  at  regular  inter- 
vals. It  will  usually  suSice  to  pass  it  thrice  in  twenty-four 
hours — namely,  in  the  morning,  at  night,  and  once  during  the 
day.  With  regular  catheterization  the  tone  of  the  bladder  fre- 
quently improves,  so  that  the  number  of  times  the  catheter  is 
passed  may  be  reduced.  When  the  residual  urine  does  not  ex- 
ceed 8  or  10  oz.  the  catheter  should  be  passed  once  a  day,  and 


XL]    PARALYSIS  OF  BLADDER  :  TREATMENT    539 

if  less  than  that  once  or  twice  a  week  will  suffice.  A  soft  rubber 
catheter  of  large  calibre  is  most  suitable  for  self-catheterization 
in  these  cases,  as  it  is  easily  kept  clean  by  boiling,  and  there  is 
no  urethral  obstruction  to  overcome.  Careful  note  should  be 
kept  of  the  quantity  of  residual  urine  as  an  indication  of  im- 
provement or  deterioration  in  the  tone  of  the  bladder. 

When  urethral  obstruction  is  present  it  must  be  removed. 

I  have  performed  prostatectomy  with  success  on  a  patient 
suffering  from  multiple  sclerosis.  Stricture  of  the  urethra  should 
be  treated  by  urethrotomy. 

2.  Prevention  and  treatment  of  cystitis. —  The  measures 
which  are  elsewhere  described  of  attaining  asepsis  in  catheteriza- 
tion should  be  adopted.  From  the  first,  urinary  antiseptics  should 
be  given  (urotropine,  hetralin,  helmitol,  etc.),  and  care  should 
be  taken  to  prevent  constipation  so  as  to  avoid  hoematogenous 
infection.  In  women  careful  cleansing  of  the  vulva  is  important 
as  a  safeguard  against  ascending  infection. 

If  infection  has  occurred  the  bladder  should  be  washed  out 
with  antiseptic  solutions,  of  which  silver  nitrate  (1  in  5,000  or 
1  in  10,000),  oxycyanide  of  mercury  (1  in  5,000)  and  iodine  (1  in 
500  to  1  in  300  of  the  tincture)  are  the  best.  The  patient  can 
be  instructed  to  do  this  by  using  an  irrigator,  or  a  trained  nurse 
may  be  provided.  Once  a  week  will  suffice  in  mild  cystitis,  but 
it  is  necessary  to  wash  the  bladder  daily  in  more  severe  cases. 
When  the  urine  is  alkaline,  sodium  acid  phosphate,  20  gr.  thrice 
daily,  should  be  administered  with  urotropine.  The  bladder  should 
be  examined  from  time  to  time  with  the  cystoscope  to  ascertain 
if  phosphatic  calculi  have  formed,  and  if  these  are  present  they 
are  removed  by  litholapaxy. 

3.  Treatment  of  atony. — With  regular  catheterization  im- 
provement in  the  tone  of  the  bladder  usually  takes  place.  The 
patient  should  be  encouraged  to  try  to  expel  the  urine.  The 
liquid  extract  of  ergot,  20-30  minims  thrice  daily,  and  liquor 
strychninse,  5  minims,  should  be  administered ;  they  are  fre- 
quently of  great  service  in  increasing  the  contractile  power  of  the 
bladder. 

The  administration  of  mercury  and  iodides  has  no  beneficial 
efiect  on  the  bladder  in  these  cases. 

The  electrical  current  may  be  used  with  advantage.  One  ter- 
minal is  placed  over  the  suprapubic  region  or  over  the  sacrum  and 
the  other  on  the  perineum,  or  a  urethral  electrode  is  introduced 
into  the  bladder  or  a  rectal  electrode  into  the  rectum.  A  urethral 
electrode  consists'  of  a  gum-elastic  bougie  enclosing  a  wire.  At 
the  proximal  end  is  a  connection  for  the  wire,  and  at  the  distal 


540  THE   BLADDER  [chap,  xl 

end  a  small  metal  cone.  A  rectal  electrode  has  a  handle  with 
a  connection  for  the  wire,  and  a  metal  cylinder  which  is  oiled  and 
introduced  into  the  rectum. 

The  interrupted  current  is  most  frequently  used,  and  the 
current  should  at  first  be  weak  and  the  sitting  short.  The  galvanic 
current  may  also  be  used,  commencing  with  3  ma.  and  rising 
gradually  to  5  ma.  or  more. 

LITERATURE 

Albarran,  Nogues,  and  others,  I«'^  Congres  de  1' Assoc.  Internat.  d'Urol.,  1908,  p.  265. 

Asch,  Miinch.  med.  Woch.,  1909,  No.  7. 

Bierhoff,  Derm.  Zeits.,  1904,  Nr.  3. 

Bdhme,  Miinch.  med.  Woch.,  Dec.  15,  1908. 

Corner,  J.W.W.  Surg.,  1901,  xxxiv.  456. 

von  Frankl-Hochwart  und  Zuckerkandl,  Die  nervosen  Erkranhungen  der  Blase.  1898. 

Goltz  und  Ewald,  Pfliigers  Arch.,  Bd.  Ixiii. 

Goltz  und  Treusberg,  Pfliigers  Arch.,  Bd.  viii.,  ix. 

Hahn,  XVI«  Congres  Internat.  de  Med.,  Budapest,  1909,  xiv.  428. 

Hertig,  Arch.  f.  Psychiatrie,  xxvii.  2. 

Hirt,   Gentralbl.  f.  d.  KranJc.  d.  Ham-  u.  Sex. -Org.,  1902. 

Le  Fur,  These  de  Paris,  1901. 

Miiller,  Deuts.  Zeits.  f.   Nervenheilk.,  1901,  p.  86. 

Rinaldo,  Gaz.  dejli  Osped.,  Jan.  18,  1910. 

Walker,  Thomson,  Ann.  Surg.,  1910,  p.  577. 


CHAPTER  XLI 
OPERATIONS  UPON  THE  BLADDER 

The  operations  upon  the  bladder  performed  for  growths,  stone, 
and  other  diseases  are  described  under  the  headings  of  these 
diseases.  Preliminary  to  most  of  these  operations  are  certain 
preparations  and  the  operation  of  cystotomy,  and  these  will 
be  described  here. 

The  general  preparation  of  the  patient  differs  in  no  way 
from  that  adopted  for  other  surgical  operations.  In  suprapubic 
operations  the  pubic  region  is  shaved,  in  perineal  operations  the 
scrotum  and  perineum  are  shaved,  and  the  whole  region  thoroughly 
washed  with  ether  soap.  The  skin  is  prepared  by  painting  with  a 
solution  of  iodine  in  rectified  spirit  (2  per  cent.)  twelve  hours 
previous  to  the  operation,  and  again  immediately  before  it. 

AYhen  an  operation  for  growth  or  prostatectomy  is  proposed, 
and  cystitis  is  present,  every  endeavour  should  be  made  to  render 
the  bladder  aseptic.  This  may  be  done  by  careful  washing  through 
a  catheter  in  the  urethra  ;  or,  if  the  cystitis  persists,  and  especially 
where  renal  complications  from  sepsis  and  back  pressure  are 
present,  a  week  or  a  fortnight  of  drainage  by  tying  in  a  catheter 
or  by  suprapubic  cystotomy  should  be  allowed  as  a  preliminary 
to  the  main  operation. 

The  preliminary  to  most  operations  upon  the  bladder  is  cyst- 
otomy, and  the  postoperative  treatment,  in  the  majority,  con- 
sists of  temporary  or  permanent  drainage.  These  two  procedures 
will  therefore  be  described. 

Cystotomy. — The  bladder  may  be  opened  above  the  pubes 
(suprapubic  cystotomy)  or  from  the  perineum  (perineal  cystotol.ny). 

Perineal  cystotomy. — This  may  rarely  be  used  for  explora- 
tion, for  the  extraction  of  foreign  bodies  and  calculi,  or  for  drain- 
age. For  all  of  these  objects  suprapubic  cystotomy  is  preferable. 
Perineal  cystotomy  is  seldom  employed,  except  in  cases  of  stric- 
ture of  the  urethra  ^vith  severe  cystitis,  or  of  stone  in  the  prostate 
or  prostatic  urethra  complicated  by  stone  in  the  bladder. 

A  curved  staff  with  a  deep  groove  on  the  convexity  of  the 

541 


542  THE   BLADDER  [chap. 

curve  is  introduced  into  the  bladder,  and  the  patient  placed  in 
the  lithotomy  position.  The  staff  is  held  vertically  by  an  assist- 
ant, who  holds  up  the  scrotum.  An  incision  1|  in.  in  length  is 
made  in  the  middle  line,  ending  |-  in.  in  front  of  the  anus.  The 
bulb  is  seen  at  the  upper  part  of  the  wound,  and  the  staff  is  made 
prominent  in  the  membranous  urethra.  The  point  of  the  knife, 
guided  by  the  left  forefinger,  enters  the  groove  in  the  staff,  and 
is  pushed  along  horizontally  into  the  prostatic  urethra.  The 
knife  is  withdrawn  and  a  probe-pointed  grooved  director  pushed 
along  the  groove  while  the  handle  of  the  staff  is  depressed  towards 
the  perineum.  This  is  replaced  by  a  gorget,  which  enters  the 
bladder,  and  the  staff  is  removed.  The  forefinger  of  the  left  hand 
is  introduced  along  the  gorget  into  the  bladder,  and  the  gorget 
then  removed.  If  the  object  of  the  operation  is  exploration  of 
the  bladder,  the  right  hand  is  placed  above  the  pubes  and  pushes 
the  bladder  downwards. 

If  drainage  is  desired,  the  gorget  is  again  slipped  into  the 
bladder,  and  a  rubber  tube  along  this. 

Suprapubic  cystotomy. — A  catheter  is  passed  and  the  bladder 
distended  with  12  oz.  of  warm  boric  lotion  by  means  of  a  bladder 
syringe.  If  the  urine  is  foul  the  bladder  is  repeatedly  washed 
before  final  distension.  The  catheter  is  left  in  the  urethra  and 
plugged.  An  incision  2^  in.  long  is  made  in  the  middle  line,  com- 
mencing just  below  the  upper  border  of  the  symphysis  (Fig.  161). 
In  a  stout  individual  this  is  prolonged.  The  anterior  layer  of  the 
rectus  sheath  is  exposed  and  cleanly  cut  in  the  middle  line.  The 
pyramidalis  and  recti  muscles  come  into  view,  and  are  split  in 
the  middle  line  with  the  handle  of  a  scalpel.  The  finger  seeks  the 
upper  border  of  the  symphysis  pubis  and  tears  through  the  trans- 
versalis  fascia.  The  pocket  of  peritoneum  which  dips  in  front 
of  the  bladder  is  pushed  upwards ;  the  bladder  wall  is  recognized 
by  its  coarse  muscle  fibres,  and  the  large  veins  which  course  over 
it  are  exposed.  The  wall  is  picked  up  with  two  pairs  of  tissue 
forceps,  and  the  knife  plunged  sharply  through  it  (Fig.  162). 
As  the  fluid  wells  up,  the  forefinger  is  inserted  into  the  cavity 
and  hooks  up  the  bladder  wall  (Fig.  163).  The  further  procedure 
depends  upon  the  object  for  which  the  cystotomy  is  performed. 

Cystotomy  with  air  instead  of  water  distension  has  no  advan- 
tage and  many  disadvantages.  Cystotomy  without  distension  is 
necessary  in  some  cases,  as  in  vesico-vaginal  fistula. 

If  possible,  a  large  metal  sound  is  introduced  along  the  urethra 
and  acts  as  a  guide.  If  no  instrument  can  be  passed  the  surgeon 
depends  upon  good  illumination  and  careful  dissection. 

After-treatment  of  the  wound. — When  the  object  of   cyst- 


XLl] 


CYSTOTOMY 


543 


otomy  has  been  attained  it  is  sometimes  possible  to  close  the  wound 
by  immediate  suture  ;  in  other  cases  temporary  drainage  will  be 
adopted  ;    in  yet  others  permanent  drainage  must  be  installed. 

Immediate  suture  is  contra-indicated  when  urethral   obstruc- 
tion or  cystitis  is  present,  when  there  is  a  danger  of  ha3morrhage, 


\ 


Fig.  161. — Suprapubic  cystotomy. 

A  vertical  median  incision  has  been  made  through  the  skin,  and  the  rectus  sheath 
is  being  incised. 

and  in  operations  affecting  the  orifice  of  the  ureter.  The  cases 
favourable  to  immediate  closure  are  cystotomies  for  aseptic  cal- 
culi or  foreign  bodies  or  small  papilloma  when  there  is  no  risk 
of  haemorrhage.     The  edges  of  the  bladder  wound  are  united  bv 


544 


THE  BLADDER 


[chap. 


interrupted  catgut  sutures  passed  through  the  whole  thickness  of 
the  wall,  including  the  mucous  membrane.  Over  these  is  placed 
a  row  of  Lemberi"'s  sutures,  and  a  drainage  tube  is  inserted  in 
the  prevesical  space,  around  which  the  abdominal  wound  is  closed. 
A  catheter  is  tied  in  the  urethra. 


Fig.  162. — Suprapubic  cystotomy. 

The  bladder,  with  its  large,  irregular  veins,  has  been  exposed  and  the  peritoneum  pushed  upwards. 
The  bladder  wall  is  seized  with  forceps  and  the  knife  plunged  vertically  through  it. 

Measures  for  providing  permanent  drainage  are  described  at 
page  549. 

Dangers. — Wounds  of  the  peritoneum  should  rarely  occur  if 
proper  care  is  taken  to  push  the  peritoneal  pouch  out  of  the  way. 


XLl] 


SUPRAPUBIC  CYSTOTOMY 


545 


If  the  peritoneum  is  opened  the  rent  is  at  once  repaired  by  means 
of  a  continuous  catgut  suture,  and  the  operation  continued.  I 
have  never  seen  ill  effects  follow  when  the  wound  has  been  recog- 
nized and  immediately  repaired. 


Fig.  163. — Suprapubic  cystotomy. 

The  finger  is  introduced  into  the  cystotomy  wound,  and  the  apex  of  the  bladder  hooked  up 
while  the  peritoneum  is  brushed  off  it  with  a  gauze  swab. 

Haemorrhage  may  take  place  from  the  veins  or  an  artery  of 
the  bladder  wall.     This  is  controlled  by  stitching  the  womid  after 
the  operation,  either  completely  closing  it  or  closing  it  around  a 
drainage  tube. 
2j 


546 


THE   BLADDER 


[chap. 


Modifications  of  suprapubic  cystotomy.  Transverse 
suprapubic  cystotomy. — A  transverse  curved  incision  about 
6  in.  long  is  made  across  the  lower  part  of  the  abdomen,  1  in. 
above  the  symphysis  pubis  and  2  in.  above  Poupart's  liga- 
ment. The  sheath  of  the  recti  muscles  is  cut  through,  and  the 
recti  and  pyramidales  muscles  divided  transversely,  one  or  two 
sutures  being  placed  through  the  upper  cut  edge  of  the  muscles 
and  assisting  in  repairing  the  abdominal  wall  after  the  operation. 
The  fascia  transversalis  is  incised  and  the  peritoneum  exposed 
and  stripped  off  the  bladder.  A  transverse  incision  is  made 
through  the  bladder  wall.  After  the  operation  careful  repair  of 
the  abdominal  wound  is  necessary ;  this  is  carried  out  by  means 
of  catgut  sutures  after  lowering  the  patient  to  the  horizontal  from 
the  Trendelenburg  position.     Free  access  is  gained  by  this  method, 


Fig.  164. — Perineal  cystotomy  drainage  tubes. 

A,  Harrison's  rigid  tube  with  metal  attachment  for  fixing  tapes.     B,  Thiclt  red  rubber  tube 
with  terminal  opening  and  a  trumpet-shaped  outer  end. 

but  there  is  great  weakening  of  the  abdominal  wall,  and  vertical 
median  cystotomy  with  incision  of  the  recti  muscles  is  preferable. 

Suprapubic  cystotomy  with  resection  of  the  pubic  bones  or 
with  symphysiotomy  has  been  performed,  but  is  very  rarely 
necessary. 

Bladder  drainage. — This  may  be  required  as  a  temporary 
measure  after  operation  on  the  bladder  or  urethra,  or  as  a  means 
of  treatment  of  cystitis.  Permanent  drainage  may  be  necessary 
in  cases  of  malignant  disease  of  the  prostate  or  bladder. 

Perineal  drainage. — This  is  used  only  when  a  perineal 
operation  has  been  performed,  and  is  unsuited  for  permanent 
drainage.  The  best  form  of  drain  is  a  flexible  rubber  tube  with 
a  terminal  opening  and  lateral  eyes  (Fig.  164,  b).  The  edges  of 
the  opening  are  smooth  and  rounded.  The  opening  of  the  tube 
should  lie  just  within  the  sphincter,  and  it  is  retained  in  position 
by  a  silkworm-gut  suture  passed  through  each  lip  of  the  perineal 
wound. 

A  stiff  gum-elastic  tube  with  a  metal  ring  which  has  lateral 


XLl] 


SUPRAPUBIC   DRAINAGE 


547 


tube 


eyes  may  be  used  (Fig.  164,  a).  The  tube  is  held  in  position  by 
passing  a  length  of  tape  through  each  eye  and  carrying  it  along 
the  fold  of  the  groin  in  front  and  the  fold  of  the  buttocks  behind. 
The  tapes  are  knotted  on  each  side  above  the  great  trochanter  and 
attached  to  a  waist-belt. 

A   short   length   of   rubber  tubing   is   attached  to   the 
and  carried  into  a  bottle  containing  antiseptic  fluid. 

Temporary  suprapubic  drainage. — 
This  is  practised  after  the  majority  of 
suprapubic  operations  on  the  bladder.  The 
drainage  must  be  free,  and  a  rubber  tube 
with  a  diameter  of  |-1  in.  should  be  used. 
The  tube  is  about  4  in.  long — longer  if 
there  is  a  considerable  development  of  fat 
— and  it  has  a  large  lateral  eye  near  the 
vesical  end.  The  tube  lies  above  the  base 
of  the  bladder,  but  does  not  press  on  it. 
The  part  of  the  bladder  wound  unoccupied 
by  this  tube  is  stitched  with  catgut  su- 
tures. A  small  rubber  tube  is  placed  in 
front  of  the  bladder  behind  the  pubes. 
The  tubes  are  held  in  position  by  silkworm- 
gut  sutures  passed  through  the  skin  after 
repair  of  the  abdominal  wound. 

Stitching  the  edges  of  the  bladder 
wound  to  the  skin  is  to  be  avoided,  as  it 
is  frequently  followed  by  a  urinary  fistula. 
After  four  or  five  days  the  tubes  should 
be  removed  and  the  wound  allowed  "co 
granulate.  It  should  close  in  fourteen  to 
twenty-one  days  from  the  operation. 

The  skin  should  be  protected  by  being 
smeared  with  an  ointment  containing  lano- 
line,  zinc  oxide,  and  castor  oil. 

Methods  of  draining  away  the 
urine. — To  avoid  the  discomfort  of  soak- 
ing the  dressings  with  urine  and  to  re- 
duce the  expense  of  dressings  many  methods  have  been  adopted. 

1.  Exhaust  methods. — Cathcart's  and  White's  apparatus  may 
be  used.  White's  (Fig.  165)  consists  of  a  water  reservoir  leading 
to  a  drop  pump  that  sucks  air  out  of  a  bottle,  which  again  is  con- 
nected with  a  double  tube  in  the  suprapubic  wound.  These 
evacuators  can  be  applied  only  during  the  short  period  that  a 
drainage  tube  is  retained  in  the  womid. 


.ms^ 


Fig.  165.— White's  ex- 
haust apparatus  for 
bladder  drainage. 


548 


THE   BLADDER 


[chap. 


2.  Siphonage. — A  small  tube  in  the  bladder  may  be  connected 
with,  a  length,  of  rubber  tubing  and  carried  into  a  vessel  below 
the  bed.  The  siphon  action  is  difficult  to  control,  and,  as  a  rule, 
acts  too  powerfully,  sucking  air,  and  eventually  the  bladder  wall, 
into  the  tube. 

I  use  a  more  satisfactory  method,  which  is  an  overflow  rather 
than  a  siphon  method.  To  the  top  of  the  large  bladder  drainage 
tube  a  length  of  Paul's  soft  rubber  colotomy  tubing  is  attached 
by  tying  a  ligature  around  it.  This  is  brought  over  the  side  of 
the  bed  into  a  bottle.  A  little  oil  should  be  run  through  the  tubing 
after  boiling,  in  order  to  prevent  the  surfaces  from  adhering. 


Fig.  166. — Hamilton  Irving's  overflow  apparatus  for 
suprapubic  cystotomy  wounds. 

3.  Overflow  apparatus. — Colt's  and  Hamilton  Irving's  are  the 
methods  in  use,  and  of  these  Irving's  apparatus  (Fig.  166)  is  the 
more  efficacious.  It  consists  of  a  celluloid  cap  with  a  movable 
perforated  lid.  This  is  fastened  over  the  wound  by  means  of 
a  rubber  belt  round  the  waist  and  two  tapes  which  pass  round 
the  perineum  to  keep  the  cap  from  riding  upwards.  Two  open- 
ings in  the  lower  part  of  the  circumference  of  the  cap  are  provided 
with  rubber  tubes  which  conduct  the  overflow  urine  into  a  recep- 
tacle between  the  thighs.  This  is  much  the  most  satisfactory 
method.  It  can  be  applied  at  the  time  of  the  operation  and  used 
until  the  wound  is  healed.  The  pressure  of  the  apparatus  tends 
to  cause  aversion  of  the  lips  of  the  wound,  and  may  slightly  delay 
healing. 


XLl] 


SUPRAPUBIC   DRAINAGE 


549 


Permanent  suprapubic  drainage. — This  may  be  required 
for  malignant  disease  of  the  prostate  or  for  other  irremediable 
obstruction. 

Having  exposed  and  opened  the  bladder  by  the  suprapubic 
route,  the  edges  of  the  bladder  wound  are  drawn  into  the  supra- 
pubic wound  and  stitched  with  catgut  to  the  sheath  of  the  rectus 
on  each  side.  The  upper  part  of  the  opening  in  the  rectus  sheath 
is  closed  with  catgut,  and  the  skin  wound  closed,  leaving  room  for 
a  rubber  tube  the  size  of  the  forefinger,  which  is  passed  into  the 
bladder  at  the  lower  end  of  the  wound.  The  wound  is  allowed  to 
contract  to  the  size  of  a  No.  12  English  rubber  catheter.  The 
catheter,  which  lies  in  the  suprapubic  fistula,  is  brought  through 
a  metal  tube  attached  to  a  metal  plate 
(Fig.  167)  that  is  strapped  to  the  abdomen. 
The  catheter  is  carried  into  a  rubber  re- 
ceptacle which  is  strapped  to  the  patient's 
thigh.  The  patient  can  get  about  and 
pursue  an  active  business  life  with  this 
apparatus  in  place. 

An  ingenious  method,  and  one  which 
promises  good  results,  has  been  intro- 
duced by  Pardoe.  The  bladder  is  ex- 
posed by  a  vertical  median  suprapubic 
incision,  and  the  peritoneum  stripped  off 
its  posterior  and  lateral  walls.  The  skin 
is  undercut  and  retracted,  exposing  the 
sheath  of  the  right  or  left  rectus,  in 
which  a  small  vertical  incision  is  made 
2  in.  from  the  middle  line.  The  rectus 
is   split   from  the   mid-line    cut   to   this 

opening,  and  a  cone  of  bladder  pulled  through  and  out  of  the 
opening  in  the  sheath,  to  the  edges  of  which  it  is  stitched.  The 
cone  is  then  brought  through  a  small  opening  in  the  skin  corre- 
sponding to  that  in  the  sheath.  The  cone  is  opened  and  a  small 
self-retaining  catheter  inserted.  The  median  wound  is  now  closed. 
After  a  few  days  the  catheter  is  removed,  and  a  rubber  catheter 
is  passed  at  intervals  through  the  fistulous  opening.  The  bladder 
may  be  continent,  or  only  a  Httle  urine  may  escape,  which  can 
be  controlled  by  a  light  truss.  The  operation  is  not  applicable  to 
contracted  or  extensively  adherent  or  infiltrated  bladders. 


Fig.  167. — Metal  plate 
with  tube  for  ca- 
theter, for  permanent 
suprapubic  drainage. 


PART  IV.~THE  URETHRA 


CHAPTER  XLII 
SURGICAL  ANATOMY 

The  male  urethra  is  about  8J  in.  long,  and  is  divided  anatomic- 
ally into  three  parts  :  the  prostatic  urethra  (If  in.),  the  membran- 
ous urethra  (|  in.),  and  the  spongy  urethra  (about  6  in.).  A  fars 
intramurales,  where  the  canal  passes  through  the  base  of  the 
bladder,  is  also  described  (E.  Zuckerkandl).  Clinically,  the  canal 
is  more  conveniently  divided  into  (1)  the  posterior  urethra,  which 
lies  behind  the  compressor  urethrae  muscle  and  corresponds  to  the 
prostatic  urethra,  and  (2)  the  anterior  urethra,  which  lies  in  front 

of  the  compressor.  The 
anterior  urethra  is  divided 
into  the  bulbous  or  perineal 
urethra,  and  the  penile, 
the  names  of  which  suffi- 
ciently explain  their  posi- 
tion and  relation. 

The  urethra  in  the  flac- 
cid state  of  the  penis  has 
an  S-shaped  curve  (Fig. 
168).  The  internal  meatus 
is  on  a  level  with  the  middle 
of  the  pubic  symphysis  and  about  2  cm.  behind  it.  From  this 
the  canal  passes  vertically  downwards  for  about  |-|  in.  to  the 
level  of  the  verumontanum,  and  at  this  point  it  turns  slightly 
forwards  and  maintains  a  forward  and  downward  direction  to  the 
junction  of  the  membranous  and  bulbous  urethra.  The  canal  now 
turns  sharply  upwards  and  forwards  along  the  under-surface  of 
the  triangular  ligament.  At  the  peno-scrotal  junction  the  urethra 
turns  vertically  downwards  in  the  flaccid  penis  to  the  meatus. 

The  penile  urethra  is  freely  movable.  At  the  base  of  the  penis, 
the  peno-scrotal  junction,  the  canal  becomes  flxed,  this  part  being 
slung  up  by  a  dense  fibro-elastic  band,  the  suspensory  ligament 

550 


Fig.  168.^ — Curves  and  dilata- 
tions of  the  urethra. 


CHAP.  XLIl] 


SURGICAL  ANATOMY 


551 


Fig.  169. — Relations  of  the  prostate,  compressor 
urethras,  bulb,  and  suspensory  ligament  to 
the  urethra. 


of  the  penis,  which  has  a  vertical  median  attachment  to  the  front 
of  the  pubic  symphysis.     (Fig.  109.) 

Behind  the   peno-scrotal   junction   the    urethra   is   fixed,    the 
corpus     spongio- 

m 


sum  being  adhe 
rent  to  the  tri- 
angular ligament. 
Between  the 
layers  of  the  tri- 
angular ligament 
the  membranous 
urethra  is  rigidly 
fixed,  and  the 
prostatic  urethra 
is  immobile,  being 
surrounded  b  y 
the  prostate 
gland.  The  fixed  curve  of  the  urethra  (Fig.  170)  is  7  cm.  long, 
and  extends  from  the  internal  meatus  to  the  peno-scrotal  junc- 
tion, the  deepest  part  of  the  curve  lying  at  the  termination  of 
the  bulbous  urethra,  the  cul-de-sac  du  hulbe.  This  is  4  cm.  from 
the  internal  meatus,  and  3  cm.  from  the  peno-scrotal  junction.  The 
angle  formed  by  these  two  segments  is  almost  a  right  angle  (93°). 
The  most  fixed  part  of  the  urethra  corresponds  to  the  triangular 
ligament. 

A  straight 
rigid  instrument, 
such  as  a  stone 
sound  or  cysto- 
scope,  the  beak 
of  which  is 
passed  into  the 
bladder,  modifies 
the  canal  in  the 
following  man- 
ner :  The  penile 
urethra  is  first 
brought  into  line  pig.  170.— Fixed  curve  of  the  urethra. 

with  the  bulbous 

urethra,  and  becomes  vertical  in  the  recumbent  position.  In 
order  to  pass  the  instrument  into  the  membranous  urethra  the 
penile  urethra  is  depressed  and  the  suspensory  ligament  of  the 
penis  dragged  upon.  This,  together  with  the  elasticity  of  the  wall 
of  the  bulbous  urethra,  allows  the  lumen  to  come  into  line  with 


552  THE  URETHRA  [chap. 

the  membranous  portion.  If  the  recti  abdominis  muscles  are 
contracted  by  the  patient  straining,  or  trying  to  raise  his  head 
and  shoulders,  the  suspensory  ligament  is  dragged  upon  and  the 
straightening  of  the  canal  is  considerably  impeded.  The  elasti- 
city of  the  prostatic  urethra,  combined  with  slight  mobility  of 
the  prostate  gland,  allows  these  parts  of  the  urethra  to  come 
into  line,  so  that  a  straight  line  passes  through  the  external 
meatus,  the  urethral  opening  in  the  triangular  ligament,  and  the 
internal  meatus;  and  the  segment  which  remains  fixed  and  im- 
mobile is  the  membranous  urethra,  in  the  grasp  of  the  triangular 
ligament. 

The  walls  of  the  urethra  lie  in  contact.  The  external  meatus  is 
a  vertical  slit,  the  penile  and  bulbous  urethra  a  transverse  slit ; 
the  membranous  urethra  is  star-shaped,  and  the  prostatic  urethra 
horseshoe-shaped  with  the  convexity  forwards,  the  internal  meatus 
also  having  this  form. 

The  calibre  of  the  urethra  varies  at  different  parts.  (Fig.  168.) 
The  narrowest  point  is  usually  the  external  meatus ;  this  part  is 
more  fibrous  and  has  less  elasticity  than  any  other.  The  external 
meatus  opens  into  the  fossa  navicularis,  a  dilatation  of  the  canal 
situated  in  the  glans  penis,  and  formed  by  an  arching  of  the  roof, 
the  floor  being  level  with  that  of  the  penile  urethra.  At  the  junc- 
tion of  the  fossa  navicularis  and  the  penile  urethra  the  canal  is 
again  narrowed ;  and  this  part,  the  valve  of  Guerin,  is  not  infre- 
quently narrower  than  the  external  meatus.  This  valve  is  com- 
posed of  a  fold  of  mucous  membrane,  which  usually  takes  the 
form  of  a  transverse  fold  on  the  roof  and  two  vertical  folds  at 
the  lateral  walls.  In  the  fossa  navicularis  anterior  to  the  roof 
fold  is  seen  the  opening  of  the  lacuna  magna,  which  passes  back- 
wards. The  penile  urethra  is  of  even  calibre.  Across  the  ffoof  of 
this,  under  full  distension,  fine  transverse  fibrous  arches  are  seen. 
These  supporting  arches  are  frequently  mistaken  for  strictures  of 
wide  calibre  by  the  tyro  in  aero-urethroscopy.  As  the  bulbous 
urethra  passes  backwards  it  gradually  dilates  until  the  opening 
of  the  membranous  urethra  is  reached,  when  the  floor  rises  sharply 
to  this  opening.  The  opening  of  the  membranous  urethra  is  thus 
on  the  roof  of  the  bulbous  urethra.  In  old  men,  and  when  the 
perineal  muscles  are  slack,  some  sagging  of  this  part  is  observed, 
so  that  a  veritable  cul-de-sac  du  hulbe  is  produced. 

The  membranous  urethra  is  firmly  closed  by  the  tonic  con- 
traction of  the  compressor  urethrse,  but  it  offers  no  obstruction 
to  the  passage  of  large  instruments.  The  normal  prostatic  urethra 
is  elastic  and  capable  of  expansion ;  the  internal  meatus  is  more 
rigid. 


XLii]  SURGICAL  ANATOMY  553 

The  following  are  the  dimensions  of  the  anterior  urethra, 
as  given  by  Calle  : — 

Meatus,  25-30  mm. 
Fossa  navicularis,  30-35  mm. 
Penile  urethra,  35-37  mm. 
Bulb,  35-38  mm. 

Otis  held  that  the  calibre  of  the  urethra  had  a  constant  rela- 
tion to  the  circumference  of  the  penis :  when  the  circumference 
was  3  ill.  (75  mm.)  the  calibre  was  30  mm.  ;  when  the  circum- 
ference was  3 J-  in.  (87  mm.)  the  calibre  was  34  mm.,  and  so  on. 
This  rule  is  not  generally  accepted,  and  has  certainly  many 
exceptions. 

Structure. — The  urethra  consists  of  a  mucous,  submucous, 
and  muscular  coat.  The  mucous  membrane  is  lined  with  columnar 
epithelium,  except  at  the  fossa  navicularis,  where  it  is  squamous. 
There  is  a  basement  membrane  surrounded  by  a  vascular  layer, 
and  this  by  a  circular  layer  of  non-striped  muscle.  In  the  penile 
urethra  the  circular  muscle  lies  on  the  ventral  surface  of  the 
urethra  only.  In  the  bulb  the  circular  non-striped  muscle  is 
well  developed ;  on  the  dorsal  wall  it  is  wanting,  but  there  is 
a  layer  of  longitudinal  fibres.  In  the  prostatic  urethra  there  is  a 
well-developed  internal  longitudinal  layer  of  non-striped  muscle 
continued  from  the  longitudinal  muscle  of  the  trigone,  and  out- 
side this  is  a  layer  of  circular  fibres. 

These  layers  are  continued  through  the  membranous  urethra. 

The  anterior  wall  of  the  prostatic  urethra  is  even  and  shows 
no  openings.  On  the  posterior  wall  is  a  vertical  ridge  commencing 
at  the  vesical  orifice  (uvula  vesicae)  and  rising  gradually  to  the 
middle  of  the  prostatic  portion,  where  it  culminates  in  an  emi- 
nence, the  verumontanum.  Below  this  the  ridge  gradually  sinks 
again.  On  each  side  of  the  ridge  is  a  gutter,  the  prostatic  sinus. 
The  ducts  of  the  prostatic  glands  open  into  the  urethra  in  the 
prostatic  sinuses  in  the  immediate  neighbourhood  of  the  veru- 
montanum and  above  this.  No  gland  ducts  open  into  the  urethra 
between  the  part  immediately  adjacent  to  the  verumontanum  and 
the  membranous  urethra. 

The  sinus  pocularis,  a  blind  tube  ^-^  in.  in  length,  opens  on 
the  verumontanum,  and  on  each  side  of  this  are  the  slit-like 
openings  of  the  ejaculatory  ducts. 

The  mucous  membrane  of  the  membranous  urethra  shows  the 
openings  of  numerous  mucous  glands.  This  portion  of  the  urethra 
is  surrounded  by  the  compressor  urethrae  muscle,  the  external 
sphincter  of  the  bladder,  and  on  each  side  lie  Cowper's  glands. 
The  mucous  membrane  of  the  anterior  urethra  is  thrown  into 


554  THE   URETHRA  [chap,  xlii 

longitudinal  folds.  In  the  mucous  membrane  there  are  numerous 
openings  of  small  mucous  glands,  the  glands  of  Littre,  the  ducts 
of  which  pass  obliquely  forward.  There  are  also  ten  or  twelve 
larger  openings  leading  into  lacunae  which  pass  obliquely  backwards 
through  the  mucous  membrane,  and  are  found  only  on  the  roof  of 
the  bulbous  and  penile  urethrse.  (Plate  40,  Fig.  1,  facing  p.  626.) 
Opening  into  the  roof  of  the  fossa  navicularis  is  the  largest  and 
most  constant  of  these,  the  lacuna  magna,  6-8  mm.  in  length. 
The  ducts  of  Cowper's  glands  converge  and  run  for  an  inch  or 
more  in  the  wall  of  the  bulbous  urethra,  opening  separately  on  the 
floor  about  this  distance  from  the  membranous  opening.  Covering 
the  under-surface  of  the  bulb  is  the  bulbo-cavernosus  muscle, 
which  acts  powerfully  in  ejecting  fluid  from  the  bulbous  urethra. 

Lymphatics. — The  lymphatics  of  the  prostatic  urethra  join 
those  of  the  prostate  and  pass  to  the  chain  along  the  internal 
iliac  vessels.  Those  from  the  membranous  and  the  bulbous 
urethra  pierce  the  triangular  ligament,  and  pass  partly  to  the 
glands  along  the  external  iliac  vessels,  and  partly  to  those  in 
relation  to  the  internal  pudic  vessels.  The  lymphatics  of  the 
spongy  portion  of  the  urethra  pass  round  the  sides  of  the  penis 
or  out  at  the  frsenum  and  join  the  lymphatics  which  accompany 
the  dorsal  vein.  At  the  base  of  the  penis  these  pass  in  a  super- 
ficial set  to  join  the  superior  group  of  inguinal  glands,  and  in 
a  deep  set  to  the  glands  along  the  femoral  vessels  or  along 
the  inguinal  canal  to  the  external  iliac  artery.  Other  lymphatics 
pass  beneath  the  pubic  arch  with  the  dorsal  vein,  and  then  join 
the  glands  along  the  external  iliac  vessels. 

Female  urethra. — The  female  urethra  is  1|  in.  in  length,  is 
almost  straight,  with  a  slight  anterior  concavity,  and  is  intimately 
united  with  the  anterior  wall  of  the  vagina.  The  internal  meatus 
is  situated  at  a  lower  level  than  in  the  male,  being  on  the  level  of 
the  lower  border  of  the  pubic  symphysis,  and  is  a  little  nearer  to  it. 

The  external  meatus  is  a  vertical  slit  immediately  in  front  of 
the  entrance  of  the  vagina.  It  is  the  narrowest  portion  of  the 
canal.  The  mucous  membrane  is  thrown  into  longitudinal  folds, 
the  most  marked  of  which  is  on  the  posterior  wall.  Numerous 
mucous  glands  and  a  few  lacunae  open  in  the  depression  between 
these  ridges.  The  epithelium  is  squamous  at  the  external  end 
and  columnar  near  the  bladder. 

LITERATURE 

Albarran,  Medecine  Opiratoire  des  Voies  Urinaires.     1909. 
Walker,  Thomson,  Med.-Chir.  Trans.,  1904,  Ixxxvii. 

Zuckerkandl,  E.,  Handhiich  der  Urologie  (von  Frisch  und  0.  Zuckerkandl),  1904, 
Bd.  i. 


CHAPTER  XLIII 


EXAMINATION  OF  THE  URETHRA— URETHRAL 
SHOCK— URETHRAL  FEVER 

EXAMINATION 

L  Inspection. — The  size  and  appearance  of  the  external 
meatus  are  examined.  In  acute  and  subacute  urethritis  the 
condition  of  the  lips  gives  a  fair  indication  of  the  state  of  the 
urethral  mucous  membrane.  Congenital  and  acquired  mal- 
formations are  noted.  A  sinus  or  fistula  may  be  found  on  one 
or  on  both  sides  of  the  frsenum. 

The  swelhng  of  a  periurethral  abscess  may  be  seen  in  the 
penile  or  bulbar  areas,  or  urinary  fistulas  may  be  found.  On 
examining  a  perineal  urinary  fistula  I  have  found  the  rounded 
end  of  a  large  urethral  calculus  projecting  through  the  opening. 

When  a  sacculus  of 
the  urethra  is  present 
it  wdll  be  seen  to  swell 
up  during  micturition 
and  subside  at  the 
end  of  the  act. 

2.  Palpation.  —  A 
small  lacunar  abscess  of 
the  penile  urethra  can 
be  felt  as  a  rounded 
body  the  size  of  small 
shot,  and  is  made  more 
evident  on  passing  a 
bougie.  Larger  ab- 
scesses are  less  defined,  and  the  skin  over  them  is  usually  reddened. 
A  cartilaginous  stricture  in  the  bulbous  or  penile  urethra  can 
frequently  be  felt  when  palpated  with  a  bougie  in  the  canal.  A 
calculus  or  foreign  body  can  be  detected  in  the  anterior  urethra, 
but  rarely  in  the  prostatic  portion  unless  it  is  of  considerable  size. 

Cowper's  glands,  when  inflamed,  can  be  felt  by  introducing  the 
forefinger   into   the   rectum,  sinking  it  alongside  the  membranous 

555 


Fig.  171. — Palpation  of  Cowper's  gland. 

The  forefinger  is  in  the  rectum  and  the  thumb  on  the  peri- 
neum, the  patient  being  in  the  knee-elbow  position. 


556  THE   URETHRA  [chap. 

urethra,  and  placing  the  thumb  upon  the  perineum  (Fig.  171). 
The  enlarged  gland  is  felt  as  a  hard  pea-sized  body  between  the 
finger  and  thumb.    It  cannot  be  felt  in  the  normal  state. 

The  membranous  urethra  is  felt  in  the  middle  line  below  the 
prostate  on  rectal  examination,  and  the  prostatic  urethra  lies  in 
the  vertical  sulcus  between  the  lobes  of  the  prostate. 

3.  Examination  of  the  urethra  with  sounds. — An  acorn- 
tipped  bougie  or  bougie  a  houle,  or  a  conical  bougie  (No.  18  Fr.), 
is  used.  The  penis  is  raised  with  the  left  forefinger  and  thumb 
behind  the  corona  glandis,  and  the  instrument,  well  oiled,  is 
passed  gently  along  the  anterior  urethra,  and  any  obstruction 
noted.  If  it  is  arrested,  the  distance  from  the  meatus  is  noted 
and  a  smaller  instrument  tried. 

There  may  be  a  creaking  in  passing  through  a  cartilaginous 
stricture,  grating  in  passing  over  a  stone  or  a  phosphatic  deposit, 
or  a  tearing  sensation  when  a  false  passage  is  made.  These  sensa- 
tions are  frequently  confused,  the  most  usual  mistake  being  to 
make  a  diagnosis  of  calculus  when  a  cartilaginous  stricture  is 
present  or  when  the  mucous  membrane  has  been  torn. 

Shght  resistance  is  felt,  or  the  bougie  is  arrested,  at  5|  or  6  in. 
from  the  meatus  when  it  reaches  the  contracted  membranous 
urethra.  When  the  urethral  muscles  are  atonic  and  a  well-marked 
cul-de-sac  du  hulbe  is  present,  the  point  of  the  bougie  sinks  past 
the  opening.  This  is  avoided  by  pressure  upon  the  perineum 
with  the  disengaged  hand,  or  by  using  a  metal  instrument  and 
raising  the  point  a  little,  so  as  to  engage  it  in  the  membranous 
opening. 

The  resistance  of  the  membranous  urethra  is  overcome  by 
gentle  pressure,  and  the  point  enters  the  prostatic  urethra.  There 
may  be  a  further  slight  resistance  at  the  entrance  of  the  bladder. 
In  cases  where  instruments  have  been  passed  for  many  years, 
the  bougie  may  be  arrested  in  a  pouch  of  the  prostatic  urethra, 
just  behind  the  entrance  into  the  bladder.  In  such  a  case  a  curved 
metal  instrument  can  be  passed  by  pulling  gently  upon  the  handle 
as  it  is  being  depressed  between  the  thighs. 

4.  Urethroscopy. — The  urethroscope  consists  of  a  tube  which 
is  introduced  into  the  urethra  and  an  apparatus  for  illumination. 
There  are  two  varieties.  In  one  the  light  is  reflected  from  a  lamp 
at  the  proximal  end  of  the  tube ;  in  the  other  the  lamp  is  placed 
in  the  lumen  of  the  tube  at  its  distal  end. 

I  use  Casper's  and  Wyndham  Powell's  patterns,  in  which  the 
light  is  reflected  into  the  tube  by  a  mirror  contained  in  the  lantern. 
The  part  of  the  lantern  that  fits  into  the  upper  end  of  the  urethral 
tube  is  provided  with  a  window  which  is  opened    by  a  spring. 


XLIIl] 


URETHROSCOPY 


557 


Below  this  is  a  tap  which  is  connected  with  a  rubber  balloon  for 
air-inflation  of  the  urethra.  (Fig.  172.)  The  electric  current  may 
be  obtained  from  the  main,  the  current  being  reduced  by  a  trans- 
former. For  travelling,  a  small  battery  or  accumulator  which 
gives  the  required  voltage  for  the  urethroscope  lamp  is  necessary. 
For  the  anterior  urethra  the  urethroscopic  tube  is  straight,  5|  in. 
long,  and  is  provided  with  an  accurately  fitting  metal  obturator. 
A  number  of  tubes  of  different  calibre  are  necessary ;  Nos.  23  to 
26  Charriere  are  useful  sizes.  The  edge  of  the  distal  end  should  be 
smoothly  rounded,  and  the  end  may  be  cut  transversely  or  obliquely, 
the  latter  giving  a  slightly  larger  field.  The  tubes  may,  for  con- 
venience of  noting  the  position  of ''diseased  areas,  be  marked  in 


-:p^^ 


Fig.  172. — Wyndham  Powell's  aero-urethroscope. 

half-inches.  It  is  convenient  to  have  one  or  two  short  tubes  for 
examination  of  the  outer  portion  of  the  penile  urethra.  A  wire 
speculum  (Smith's),  or  the  slightly  more  elaborate  speculum  of 
Watson,  may  be  used  with  reflected  light  for  the  first  inch  or  so  of 
the  urethra. 

The  urethroscopes  of  Luys  and  Valentine  are  the  most  perfect 
of  those  with  an  internal  lamp.  They  are  open  to  the  objections 
that  the  lamp  tends  to  become  overheated  in  a  prolonged  examina- 
tion, and  may  scorch  the  mucous  membrane  ;  that  applications 
of  fluids  tend  to  obscure  the  light ;  and  that  the  lamps  are  very 
small  and  sensitive,  and  are  quickly  destroyed  by  variations  in 
the  electric  current. 

For  operations  on  the  anterior  urethra  the  open  urethroscopic 
tube  is  used.     It  is  occasionally  of  benefit  to  have  the  urethra 


558 


THE  URETHRA 


[CHAP. 


distended  during  the  incision  of  a  lacuna  or  small  abscess,  and 
for  this  purpose  Wyndham  Powell  has  introduced  a  modification 
of  his  urethroscope  (Fig.  173).  Attached  to  the  lantern  between 
the  glass  window  and  the  nozzle  which  fits  into  the  urethroscopic 
tube  is  a  soft  indiarubber  cylinder  which  allows  the  lantern  to  be 
manipulated  vertically  while  air-pressure  is  maintained.    The  fine 


Fig.  173. — Wyndham  Powell's  operating 
aero-urethroscope. 

urethral  knife  or  probe  or  electrode  is  attached  inside  this,  and  is 
controlled  by  manipulating  the  lantern. 

For  examination  of  the  prostatic  urethra  a  longer  tube  (6|  in.) 
with  a  well-curved  beak  (1  in.)  should  be  used  (Fig.  174).  An  open 
window  is  situated  at  the  convexity  of  the  junction  of  beak  and 
shaft.  The  tube  is  fitted  with  an  obturator  during  introduction. 
More  elaborate  instruments  for  the  examination  of  the  prostatic 
urethra  are  the  urethroscopes  of  Goldschmidt  and  Wossidlo.  These 
consist  of  a  beaked  tube  with  an  opening  in  the  shaft  near  the  beak. 


Scale    3 


Fig.  174. — Tube  for  examining  prostatic  urethra. 

Illumination  is  supplied  by  a  fixed  lamp  at  this  opening,  which 
is  cooled  by  a  water  circulation.  A  telescope  is  introduced  along 
the  tube  after  removing  the  obturator.  These  tubes  have  the 
disadvantage  of  a  large  calibre,  23  or  24  Charriere. 

Operations  upon  the  posterior  urethra  are  carried  out  through 
the  open  tube  of  the  prostatoscope  by  means  of  fine  electro- 
cauteries, curettes,  alligator  forceps,  and  other  specially  con- 
structed instruments.     (Figs.  175,  176.) 


XLIIl] 


URETHROSCOPY 


559 


The  Wossidlo  urethroscope  (Fig.  177)  has  been  modified  by 
H.  E.  Wossidlo  to  permit  of  free  manipulation  of  the  probe,  fine 
cautery,  or  curette  in  view  of  the  window  of  the  telescope.  These 
instruments  pass  along  the  lumen  of  the  tube  below  the  very  fine 
telescope,  and  there  is  room  for  some  excursion  of  the  point  of 
the  instrument  in  all  directions. 


Fig.  175. — Urethral  cautery. 


A  number  of  long,  fine,  metal  wool-carriers  are  necessary  for 
swabbing  the  urethra  clear  of  lubricant,  pus,  etc.  Fine  urethral 
knives,  probes,  snares,  and  syringes  complete  the  armamentarium. 
(Fig.  178.) 

Technique  of  urethroscopy. — For  anterior  urethroscopy  the 
patient  lies  flat  on  a  high  table,  and  the  surgeon  stands  on  his  right 
side ;    or  the  patient  may  be  recumbent,   with  the  buttocks  at 


Alligator  forceps. 


the  end  of  the  table,  the  thighs  horizontal,  the  knees  bent,  and 
the  feet  in  inverted  stirrups,  the  surgeon  standing  between  the 
thighs.  All  parts  of  the  urethroscope  are  carefully  examined, 
the  lamp  tested,  and  the  air-bulb  blown  up  with  the  tap  closed. 
The  glans  and  meatus  are  cleansed,  and  the  anterior  urethroscope 
tube,  with  the  obturator  in  position,  lubricated  with  sterilized 
olive  oil  and  very  gently  introduced.     The  instrument  sinks  as 


560 


THE   URETHRA 


[chap. 


far  as  the  membranous  opening,  the  obturator  is  removed,  a  pledget 
of  cotton-wool  on  a  carrier  introduced  to  remove  the  oil,  the  lan- 
tern applied  to  the  tube,  and  the  light  switched  on.  The  urethra 
is  examined  as  the  tube  is  slowly  withdrawn.     The  tap  of  the 


Fig.  177. — Wossldlo's  urethroscope  for  examination  of  the 
prostatic  urethra. 

A  snare  and  a  fine  cautery  are  shown,  for  urethroscopic  operations. 

air-bulb  is  now  opened,  and  the  urethra  is  distended  like  a  tunnel. 
If  during  the  introduction  an  obstruction  is  felt,  the  examination 
commences  here.  Air  distension  is  especially  useful  in  examin- 
ing strictures,  particularly  multiple  strictures  and  those  of  large 
calibre. 


Fig.  178. — Armamentarium  for  use  in  operation  through 
Wossidlo's  urethroscope. 

A  punch,  cautery,  probe,  and  curette  are  shown. 

In  the  normal  urethra  the  mucous  membrane  varies  from 
pink  to  red,  the  colour  being  deeper  in  the  bulbous  urethra.  It 
is  supple  and  light-reflecting,  and  shows  longitudinal  folds,  and 
the  vessels  appear  as  longitudinal  red  markings.  The  membran- 
ous opening  appears  as  a  central  depression  from  which  radiate 


xLiii]  URETHROSCOPY  561 

numerous  fissures.  Under  air-distension  the  wall  recedes  and 
the  upper  lip  of  the  opening  forms  a  sharply  cut,  rounded  arch, 
while  the  floor  rises  sharply  and  passes  behind  this.  There  may 
be  a  momentary  relaxation  of  the  opening  as  it  swallows  a  gulp 
of  air,  and  then  it  closes  again.  On  withdrawing  the  tube  slowly 
and  keeping  up  the  air  pressure,  the  longitudinal  striation  of  the 
mucous  membrane  is  seen  to  be  well  marked  on  the  floor  of 
the  bulbous  portion.  A  central  ridge  may  be  found  passing  along 
the  centre  of  the  floor  for  about  an  inch.  This  is  formed  by  the 
ducts  of  Cowper's  glands,  the  openings  of  which  can  sometimes 
be  seen  about  an  inch  from  the  membranous  opening. 

As  the  tube  is  withdrawn  the  air  pressure  may  be  relaxed  and 
then  re-established,  and  the  mucous  membrane  is  seen  to  be 
supple  and  to  fall  evenly  over  the  end  of  the  tube.  Collapsed, 
it  forms  a  central  point  from  which  radiate  several  fine  fissures, 
and  the  longitudinal  striation  can  be  clearly  seen.  If  the  penis 
is  not  held  in  line  with  the  bulbous  urethra,  a  transverse  fold 
appears  on  the  floor  at  the  peno-scrotal  junction,  which  might  be 
mistaken  for  a  stricture.  It  disappears  on  making  the  urethra  tense. 
On  the  roof  of  the  bulbous  and  penile  urethra  the  openings  of 
lacunae  are  seen  (Plate  40,  Fig.  1,  facing  p.  626),  varying  in 
size  from  a  minute  point  to  a  pin's  head.  They  are  red  and  open, 
but  are  not  normally  surrounded  by  inflamed  or  cedematous  mucous 
membrane,  and  no  discharge  issues  as  the  urethroscope  tube  passes 
over  them.  In  full  air-distension  numerous  whitish  transverse 
arches  appear  on  the  roof.  These  bands  should  not  be  mistaken 
for  strictures  of  large  calibre.  The  fold  of  Guerin  is  seen  at  the 
base  of  the  glans,  either  as  two  lateral  folds  or  sometimes  as  a 
circular  narrowing,  and  the  opening  of  the  lacuna  magna  is  found 
on  the  roof  of  the  fossa  navicularis.  The  latter  is  the  largest 
opening  on  the  roof  of  the  urethra,  and  is  bounded  below  by  a 
transverse  fold  of  mucous  membrane. 

For  examination  of  the  prostatic  urethra  a  local  anaesthetic  is 
necessary,  and  a  solution  of  cocaine  sulphate  (1  per  cent.),  or  of 
alypin  with  suprarenal  extract  or  of  eucaine  with  suprarenal 
extract,  is  used.  Twenty  minims  of  the  solution  are  introduced 
into  the  prostatic  urethra  by  means  of  a  Guyon's  syringe.  The 
patient  lies  on  a  high  couch  with  the  pelvis  raised  on  a  cushion, 
or,  better  still,  is  placed  on  a  special  chair  with  the  hips  and 
knees  flexed.  The  posterior  urethroscope  tube,  well  lubricated,  is 
passed  through  the  anterior  urethra  and  depressed  so  that  the 
beak  passes  into  the  prostatic  urethra  and  enters  the  grasp  of 
the  sphincter  vesicae. 

The  obturator  is  withdrawn  and  a  tampon  of  wool  introduced. 
2k 


562  THE   URETHRA  [chap. 

The  lantern  is  applied  with  the  glass  window  open  and  the  light 
switched  on. 

The  verumontanum  is  seen  projecting  into  the  window,  and  the 
sinus  pocularis  can  be  clearly  seen,  but  the  openings  of  the  ejacu- 
latory  ducts  are  not  visible.  On  either  side  are  the  prostatic 
sinuses.    Below  the  verumontanum  the  inframontanal  ridge  is  seen. 

Only  the  posterior  and  part  of  the  lateral  walls  can  be  seen, 
but  in  practice  this  is  all  that  is  necessary,  as  diseases  of  the 
prostatic  urethra  are  confined  to  this  area.  In  the -most  recent 
forms  of  prostatoscope  the  supramontanal  ridge  and  the  junction 
of  the  urethra  and  bladder  can  be  inspected. 

Pathological  conditions  which  may  be  observed  include  swell- 
ing and  redness  of  the  lips  of  the  sinus  pocularis  and  the  pre- 
sence of  pus  at  this  orifice,  distortion  of  the  verumontanum  and 
prostatic  urethra  from  long-standing  inflammation,  polypi,  and 
granulation  tissue  due  to  chronic  posterior  urethritis  or  to  tuber- 
culous disease  spreading  from  the  bladder  or  prostate. 

After  examination  of  the  prostatic  urethra  the  patient  should 
rest  in  bed  for  at  least  twenty-four  hours,  and  should  take  a 
diuretic  mixture  containing  urotropine. 

Female  urethra. — The  female  urethra  can  be  palpated  on 
the  anterior  wall  of  the  vagina,  and  should  be  examined  for  tender- 
ness, thickening,  or  the  presence  of  new  growths  or  foreign  bodies. 

The  urethroscope  can  be  used  as  in  the  male,  but  without  air- 
distension. 

LITERATURE 

Buerger,  Folia  Urol.,  1911,  Heft  1. 

Dreyer,  Zeits.  f.  Urol.,  1909,  Nr.  5. 

Fenwick,   Obscure  Diseases  of  the   Urethra.     1902. 

Goldsehmidt,  Folia  Urol.,  1907,  Heft  1  ;    1910,  Heft  9. 

Kollmann  und  Oberlander,  Die  chronische  Gonorrhoe  der  mannlichen  Harnrohre, 

2  Auf.     1905. 
Oberlander,  Lehrbuch  der  Urethroskopie.     1893. 
Oberlander,  Wossidio,  und  Frank,  III.  Kongress  Verhandl.  d.  deuts.  Gesell.  f.  Urol., 

1911. 
Walbarst,  Med.  Bee,  1906,  p.  627. 

Wossidio,  E.,  Berl.  klin.   Woch.,  1912,  Nr.  25;    Folia  Urol.,  1912,  S.  40. 
Wossidio,  H.,  Folia  Urol.,  1911,  S.  445. 

ASEPSIS   IN  URETHRAL  INSTRUMENTATION 

The  rules  of  asepsis  which  guide  the  surgeon  in  regard  to  the 
sterilization  of  his  hands  and  the  surroundings  of  the  patient  in 
general  surgery  apply  with  equal  force  to  instrumental  interference 
in  the  urethra  and  bladder.  In  addition  to  this,  special  care  must 
be  given  to  the  instruments,  the  lubricant,  and  the  urinary  tract 
of  the  patient. 


xLiii]         ASEPSIS   IN   INSTRUMENTATION  563 

Solid  metal  instruments  should  have  a  smooth  plated  sur- 
face. If  this  becomes  rough  from  wear,  or  chipped  or  cracked, 
the  instrument  should  be  replated.  These  instruments  are  boiled 
for  ten  minutes  in  water  containing  1  per  cent,  of  soda  (sodium 
carbonate),  and  then  placed  upon  a  dry  sterilized  towel,  or  in 
a  shallow  tray  containing  weak  carbolic  lotion,  1  in  80,  or  bin- 
iodide  of  mercury,  1  in  5,000,  care  being  taken  to  remove  the 
lotion  with  a  sterile  mop  before  using  the  instrument.  After  use 
the  lubricant  is  removed  and  the  instrument  again  boiled,  and 
stored  dry. 

Metal  catheters  should  have  the  terminal  portion  beyond  the 
eye  solid,  otherwise  this  forms  a  pocket  for  the  collection  of  septic 
material.  They  are  treated  in  the  same  manner  as  solid  metal 
instruments,  care  being  taken,  especially  in  the  smaller  sizes,  to 
see  that  the  lumen  is  free  by  passing  a  stream  of  lotion  through 
it.  After  use  the  interior  should  be  washed  by  injecting  lotion 
by  means  of  a  sjrringe,  the  lubricant  is  removed,  and  the  instru- 
ment is  then  boiled,  dried,  and  stored. 

Eubber,  gum-elastic,  and  silk-wove  instruments  require  very 
careful  attention.  The  surface  must  be  absolutely  smooth,  with- 
out cracks,  and  the  covering  material  flexible.  On  the  first 
appearance  of  roughness  at  the  tip  or  cracking  of  the  body  the 
instrument  should  be  discarded.  Such  damaged  instruments  are 
very  dangerous  ;  they  harbour  germs,  and  rubber  instruments  in 
this  condition  are  very  brittle,  and  portions  may  be  broken  off  and 
left  in  the  bladder  or  urethra.  In  flexible  catheters  the  terminal 
portion  beyond  the  eye  must  be  solid,  and  the  interior  of  the 
catheter  as  smooth  as  the  exterior.  Information  in  regard  to  the 
state  of  the  interior  can  be  obtained  by  the  sense  of  touch  in 
passing  a  stilet  with  a  fine  pledget  of  cotton-wool  along  the 
lumen.  If  any  doubt  remains,  the  proximal  end  of  the  catheter 
should  be  cut  off  obliquely  and  the  interior  examined.  These 
instruments,  if  well  made,  withstand  boiling.  Rubber  catheters 
after  repeated  boiling  tend  to  become  soft. 

Flexible  bougies  and  catheters  should  be  placed  in  boiling  satu- 
rated solution  of  ammonium  sulphate  or  in  water  to  which  sodium 
chloride  has  been  added.  Care  should  be  taken  that  the  air  is 
expelled  from  the  interior  of  the  catheters,  and  they  should  lie 
upon  a  wire  tray,  so  that  contact  with  the  bottom  of  the  sterilizer 
is  prevented.  In  removing  a  catheter  from  the  sterilizer  it  must 
not  be  seized  in  the  middle  with  forceps  or  other  metal  instruments, 
as  the  covering  is  soft  and  will  certainly  break.  The  tray  of  the 
sterilizer  should  be  removed,  and  the  catheter  tilted  into  cold 
sterile  water  in  a  tray,  or  a  piece  of  tape  may  be  tied  round  the 


564  THE   URETHRA  [chap. 

catheter  to  facilitate  removal,  or  the  open  trumpet  end  may  be 
picked  up  with  forceps  and  the  instrument  dropped  into  a  tall  glass 
jar  filled  with  cold  sterile  water.  A  very  useful  and  easily  carried 
sterilizer  for  catheters  is  that  introduced  by  Prof.  Zuckerkandl. 

After  use  the  catheter  should  be  syringed  through  with  car- 
bolic or  biniodide  lotion,  or  it  may  be  attached  to  a  water-tap 
by  an  apparatus,  and  water  passed  through  it  in  this  manner. 
The  lubricant  is  carefully  removed  from  the  surface,  and  the 
instrument  washed  in  soap  and  water  and  dried.  A  mop  with  a 
drop  of  sterilized  olive  oil  should  then  be  passed  over  the  sur- 
face (except  in  rubber  catheters),  so  that  a  trace  of  oil  remains 
on  the  catheter  and  keeps  it  from  cracking.  The  catheters  are 
stored  in  a  japanned  tin  tray  or  in  a  glass  tube,  a  little  lycopodium 
powder  being  dusted  over  them.  Special  sterilizable  metal  boxes 
for  carrying  catheters,  and  containing  a  bottle  of  lubricant,  may  be 
obtained  at  any  good  instrument  maker's.  It  is  very  important 
that  the  instruments  should  be  absolutely  dry,  for  even  a  trace  of 
moisture  will  make  the  surfaces  of  the  catheter  adhere  and  become 
rough.  On  this  account  glass  tubes  should  be  open  at  both  ends, 
with  rubber  stoppers,  to  allow  of  thorough  drying  of  the  interior. 
Condensation  of  moisture  on  the  interior  is  prevented  by  leaving 
the  stoppers  out  occasionally. 

Formalin  may  be  used  as  an  antiseptic,  and  when  large  num- 
bers of  flexible  instruments  are  employed  this  is  a  convenient 
method  of  sterilization.  The  formalin  sterilizer  consists  of  a  metal 
box  containing  perforated  trays  in  which  the  instruments  lie.  A 
cup  on  the  floor  holds  the  formalin,  and  under  this  is  a  spirit-lamp. 
The  formalin  is  vaporized,  and  the  box  kept  closed  for  several 
hours,  and  then  filtered  air  pumped  through  it  to  remove  the  irri- 
tating vapour.  A  glass  tube  with  a  perforated  box  in  the  stopper 
containing  a  granular  preparation  of  formalin  may  be  used  for 
a  small  number  of  catheters,  but  there  is  a  tendency  for  moisture 
to  collect  and  destroy  the  catheters. 

A  cystoscope  may  be  sterilized  by  washing  it  with  methylated 
spirit  or  ether  soap,  and  then  with  carbolic  lotion,  1  in  20,  or 
biniodide  of  mercury,  1  in  2,000.  In  the  irrigation  cystoscope 
care  should  be  taken  to  clean  the  interior  of  the  irrigating  tube, 
and  especially  the  valve  at  the  end  of  this,  which  should  be  detached 
and  boiled.  In  the  author's  pattern  of  irrigation  cystoscope  the 
irrigating  tube  can  be  boiled,  and  the  valve  is  so  constructed  that 
the  spring  lies  outside  the  lumen,  and  there  is  no  dead  space  for 
the  collection  of  septic  material. 

The  lubricant  should  be  aseptic.  Boiled  olive  oil  is  the  best 
lubricant,  and  may  be  kept  in  a  wide-mouthed,  stoppered  jar,  float- 


XLiii]  URETHRAL   SHOCK  565 

ing  on  biniodide  solution.  Liquid  parafiin  or  vaseline  may  also 
be  used,  or  the  following  formula :  Phenolis,  1  part ;  olei  ricini, 
7  parts ;    olei  amygdala),  8  parts. 

For  cystoscopy  no  greasy  lubricant  can  be  used,  as  it  would 
obscure  the  window  of  the  telescope.  Glycerine  is  the  best  lubri- 
cant for  this  purpose,  and  1  drachm  of  biniodide  of  mercury 
solution  (1  in  2,000)  should  be  added  to  each  ounce. 

Urinary  antiseptics  should  be  used.  If  instruments  are  being 
passed  once  or  twice  a  week,  urotropine  (5  or  10  grains  thrice  daily) 
should  be  given  continuously ;  if  the  intervals  between  instrumen- 
tation are  longer,  the  medicine  should  be  given  for  two  days  before 
and  two  days  after  each  operation.  A  diuretic  water  such  as 
Contrexeville  may  be  given  with  advantage  during  the  same  period. 
Before  an  instrument  is  passed  the  penis  should  be  washed ;  and 
if  there  is  urethral  sepsis  the  urethra  should  be  irrigated  with 
permanganate  of  potash  solution,  1  in  5,000,  or  solution  of  nitrate  of 
silver,  1  in  10,000. 

UEETHRAL  SHOCK 

A  mild  degree  of  urethral  shock  is  not  uncommon  in  nervous 
individuals.  It  occurs  especially  on  the  first  instrumentation,  but 
may  recur  on  subsequent  occasions.  In  such  patients  the  urethra 
is  usually  hypersensitive.  The  patient  feels  faint  and  sick,  his 
pupils  dilate,  the  skin  becomes  pale  and  clammy,  and  the  pulse 
rapid  and  feeble,  and  he  may  faint. 

True  urethral  shock  is  rare,  and  is  a  much  more  serious 
condition. 

After  an  immunity  of  eight  years,  during  which  instruments 
were  passed  on  an  average  of  well  over  one  hundred  cases  each 
week,  three  cases  occurred  in  a  month  in  middle-aged  men  in 
my  out-patient  department  at  St.  Peter's  Hospital,  two  of  which 
were  fatal.  In  all  these  cases  a  stricture  was  present  and  had 
been  examined  with  the  urethroscope  under  air-distension  with- 
out roughness,  and  no  instrument  had  been  passed  through  the 
stricture  ;  after  withdrawal  of  the  instrument  the  patient  gave 
a  few  short  gasps  and  became  unconscious,  one  or  two  inspiratory 
stridors  followed,  and  breathing  stopped.  Half  a  minute  later 
a  single  loud  expiratory  efiort,  like  the  commencement  of  a  violent 
sneeze,  occurred;  the  pupils  became  dilated,  the  pulse  imper- 
ceptible at  the  wrist,  and  after  about  a  minute  the  heart  sounds 
ceased.  Stimulation,  tracheotomy,  and  artificial  respiration  were 
unavailing.  Post  mortem  the  heart  muscle  was  thin  and  friable, 
but  there  was  no  valvular  lesion.  There  was  a  moderate  degree 
of  interstitial  nephritis  secondary  to  the  stricture. 


566  THE   URETHRA  [chap. 

UEETHRAL,   URINARY,   OR  CATHETER  FEVER 

After  tke  passage  of  an  instrument  a  rise  of  temperature  may 
take  place,  when  urinary  or  catheter  fever  is  said  to  be  present. 

Two  theories  were  formerly  held  to  explain  the  occurrence 
of  urethral  fever  when  the  urethra  is  intact.  In  one,  the  rise  of 
temperature  was  ascribed  to  a  nervous  origin ;  in  the  other,  it 
was  held  to  be  due  to  sepsis.  The  two  conditions  were  supposed 
in  some  cases  to  act  in  combination ;  in  others,  apart.  Our 
present  knowledge  of  the  absorption  of  toxins  and  the  access  of 
bacteria,  especially  from  the  intestine,  into  the  circulation  through 
minute  lesions,  or  even  through  apparently  intact  membranes, 
renders  the  nervous  theory  unnecessary,  and  it  is  now  generally 
accepted  that  urethral  fever  in  all  its  forms  is  septic  in  origin. 

The  infection  either  originates  in  a  septic  instrument,  or  the 
urethra  is  already  infected,  or  becomes  infected  by  septic  urine. 
Infection  is  most  frequently  produced  by  a  septic  instrument. 
The  following  conditions  may  be  present : — 

1.  The  urethra  is  healthy  and  the  urine  aseptic,  and  the  infec- 
tion is  introduced  by  the  catheter.  2.  There  is  obstructive  disease 
in  the  urethra  (stricture,  enlarged  prostate),  but  the  urine  is 
aseptic,  the  infection  being  introduced  by  the  catheter.  3.  The 
urine  and  urethra  are  already  infected,  with  or  without  the 
presence  of  an  obstructive  lesion  (chronic  urethritis,  chronic 
prostatitis,  cystitis,  stricture,  enlarged  prostate). 

The  surgical  interference  in  the  urethra  is  usually  the  passage 
of  a  catheter ;  but  the  passage  of  solid  instruments,  and  opera- 
tions on  the  urethra,  such  as  internal  urethrotomy,  are  also  causes 
of  urethral  fever. 

Infection  is  more  likely  to  take  place  when  an  obstructive 
lesion  is  present  than  in  an  unobstructed  urethra,  in  lesions  of 
the  bulbous  than  of  the  penile  urethra,  and  in  lesions  of  the 
prostatic  than  of  the  anterior  urethra. 

A  rough,  inexperienced  hand  is  more  likely  to  produce  urinary 
fever  than  a  gentle,  educated  touch.  Fever  tends  to  follow  sudden 
or  gradual  increase  in  urinary  pressure  when  sepsis  is  already 
present.  Thus  it  appears  on  the  sudden  impaction  of  a  stone  in 
the  ureter  or  urethra,  on  the  blockage  of  a  kidney  the  seat  of 
pyelonephritis,  as  by  sudden  swelling  of  the  mucous  membrane 
due  to  an  excessive  dose  of  vaccine,  and  also  during  the  first  few 
days  after  the  closure  of  a  suprapubic  wound  when  sepsis  is 
present. 

Types  of  urethral  fever.  1.  Urethral  fever  without 
suppression    of    urine. — (a)   A  rise  of  temperature  to    100°  or 


XLIIl] 


URETHRAL   FEVER 


567 


101°  F.  may  occur  with  slight  malaise,  and  the  temperature  fall 
again  to  normal. 

(b)  A  single  severe  rise.  A  few  hours  after  the  passage  of  an 
instrument  the  patient  has  a  rigor,  and  the  temperature  rapidly 
mounts  to  102°  F.  or  higher.  The  patient  is  restless  and  ill,  the 
tongue  dry,  the  mouth  parched,  and  there  is  burning  thirst.  The 
urine  is  scanty  and  high-coloured.  In  twenty-four  or  thirty- 
six  hours,  after  profuse  perspiration,  the  temperature  falls  to 
normal. 

(c)  In  a  third  type  the  fever  is  prolonged  (acute  remittent 
type).  After  an  initial  rigor  the  temperature  rises  to  102°  F.  or 
higher,    remaining    high    for    several 

days,  and  then  falling  gradually  to 
normal,  sometimes  rising  again,  but 
eventually  falling  to  normal. 

(d)  A  rigor  follows  internal  ure- 
throtomy or  the  passage  of  instru- 
ments, and  the  temperature  rises  to 
103°  or  104°  F.,  and  falls  in  a  few 
hours  or  after  a  varying  interval.  A 
second  rigor  occurs  -with  another  rise 
of  temperature,  and  the  rigors  are 
repeated  at  irregular  intervals.  The 
quantity  of  urine  is  diminished  during 
the  high  temperature,  but  suppression 
does  not  take  place.  Venous  throm- 
bosis, pneumonia,  or  other  complica- 
tions eventually  supervene,  and  the 
patient  dies  after  several  weeks. 


DATE 

24- 

25 

26 

27 

28 

29 

106 
105 
104- 
103 
102 
101 
100 
99 
98 

M   t 

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M  E 

U   E 

M  C 

M  1   E 

- 

OOxer^ 

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1 
/ 

% 

i: 

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A 

A 

«4 

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7^ 

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1  / 

J 

V 

2.   Urethral  fever  with  suppres- 


Chart  17.  —  Temperature 
chart  in  suppression  of 
urine  following  internal 
urethrotomy. 


sion  of  urine. — [a)  There  is  a  rigor 
within  a  few  hours  after  internal  ure- 
throtomy, and  the  temperature  rises  to  104°  F.  or  even  higher- 
A  few  ounces  of  bloody  urine  are  passed,  and  the  secretion 
becomes  completely  suppressed.  .  The  patient  is  restless  and 
wanders.  He  becomes  rapidly  comatose,  and  dies  within  eighteen 
to  thirty-six  hours  of  the  operation.  The  condition  is  one  of 
sudden  and  very  profound  toxaemia,  of  which  the  suppression  is 
the  result.     (Chart  17.) 

(6)  After  the  passage  of  a  catheter  in  a  case  of  enlarged  pros- 
tate there  is  a  rise  of  temperature,  and  the  tongue  is  dry  and 
glazed. 

The  patient  is  drowsy  and  heavy,  and  wanders  at  night.  The 
temperature  remains  high ;  buccal  dysphagia,  hiccough,  and  vomit- 


568  THE   URETHRA  [chap,  xliii 

ing  follow ;  the  quantity  of  urine,  previously  large,  diminislies, 
and  complete  suppression  may  supervene.  Death  frequently 
results  from  this  form  of  catheter  fever,  which  is  a  grave  danger 
at  the  commencement  of  "  catheter  life." 

Treatment. — Prophylactic  measures  are  very  important.  The 
sterilization  of  all  instruments  should  be  carefully  carried  out. 
When  the  passage  of  instruments  is  to  be  undertaken  in  cases 
where  the  urine  is  septic,  previous  treatment  should,  if  possible, 
be  carried  out,  such  as  washing  the  urethra  with  weak  nitrate-of- 
silver  solution  or  other  antiseptics,  and  the  administration  of 
urinary  antiseptics  by  the  mouth.  Diuretics  such  as  Contrexe- 
ville  water  should  also  be  given. 

The  prophylactic  treatment  that  should  be  adopted  before  and 
after  the  operations  of  internal  urethrotomy  and  litholapaxy  is 
described  under  those  operations. 

The  precautions  necessary  for  the  emptying  of  a  distended 
bladder  obstructed  by  an  enlarged  prostate  are  given  under  that 
head  (p.  703).  When  infection  has  occurred,  a  smart  purge  should 
be  administered,  diuretics,  such  as  large  quantities  of  Contrexeville 
water,  or  barley  water,  freely  given,  and  urinary  antiseptics  (uro- 
tropine,  hetralin,  helmitol)  administered.  If  the  infection  is  due 
to  the  bacillus  coli  in  pure  culture,  large  doses  of  alkalis  (potassium 
citrate)  should  be  given. 

A  catheter  should  be  tied  in  the  urethra,  and  kept  in  until  the 
temperature  has  fallen.  In  severe  cases,  when  this  method  is 
unsuccessful,  suprapubic  drainage  with  a  large  rubber  tube  in 
the  cystotomy  wound  should  be  installed. 

Vaccine  and  serum  treatment  may  be  tried. 

The  abdomen  should  be  carefully  examined  for  evidence  of 
pyelonephritis ;  and  should  the  kidney  be  found  enlarged  or  tender, 
and  the  temperature  persist,  nephrotomy  and  drainage  of  the 
kidney  should  be  rapidly  performed.  If  there  is  urethral  ob- 
struction, suprapubic  cystotomy  should  be  performed  at  the 
same  time. 


CHAPTER  XLIV 

CONGENITAL  MALFORMATIONS  OF  THE 
URETHRA 

The  development  of  the  urethra  has  already  been  described  {see 
p.   392). 

CONGENITAL  ABSENCE   OR   OBLITERATION   OF   THE 

URETHRA 

This  is  rare.  The  penis  is  absent  or  rudimentary,  and  other 
malformations  are  present.  A  communication  frequently  exists 
between  the  bladder  and  rectum,  which  opens  just  inside  the 
anus.  Absence  of  the-  urethra  has  also  been  observed  in  female 
subjects,  the  urine  being  discharged  at  the  umbilicus  or  passing 
through  a  fistula  into  the  distended  uterus,  and  thence  by  another 
fistula  into  the  rectum.  The  children  are  usually  stillborn,  or  die 
soon  after  birth.  Distension  of  the  bladder  may  give  rise  to  difl&- 
culty  in  parturition. 

No  operative  treatment  is  possible,  and  the  treatment  consists 
in  the  administration  of  urinary  antiseptics  and  other  palliative 
measures. 

PARTIAL  OBLITERATION  OF   THE  URETHRA 

This  may  be  found  at  the  glans,  in  the  bulbous,  membranous, 
or  prostatic  urethra. 

The  prepuce  may  be  adherent  and  the  orifice  closed,  or  there 
may  be  atresia  of  the  orifice  of  the  glandular  urethra,  or  absence  of 
a  canal  in  the  glans  penis,  the  urethra  ending  blindly  at  the  base 
of  the  glans.  In  such  a  case  there  may  be  a  depression  on  the 
end  of  the  glans. 

Obliteration  of  other  parts  of  the  urethra  is  less  common. 
Kauffmann  found  that  the  order  of  frequency  was — spongy  urethra 
(11),  membranous  urethra  (7),  and  prostatic  urethra  (1). 

Multiple  obliteration  of  the  male  urethra  has  been  observed,  and 
the  female  urethra  may  be  obliterated.  The  results  of  the  oblitera- 
tion depend  upon  the  presence  or   absence  of   an   outlet   for  the 

569 


570  THE   URETHRA  [chap. 

urine  other  than  the  urethra.  If  no  outlet  is  present  and  the 
kidneys  are  active,  the  bladder  becomes  greatly  distended  and 
fills  the  abdomen,  causing  difficulty  in  parturition.  The  ureters 
and  kidneys  also  become  dilated.  The  kidneys,  too,  may  be  the 
seat  of  congenital  malformation  or  of  interstitial  changes,  and 
be  inactive,  and  distension  of  the  urinary  passages  does  not  take 
place.  An  outlet  for  the  urine  may  be  present  in  the  form  of  a 
patent  urachus,  or  a  communication  with  the  rectum  either  direct 
or  through  the  uterus.  In  the  latter  case  urine  may  escape  through 
the  Fallopian  tubes  into  the  peritoneal  cavity,  or  by  a  penile  or 
vaginal  fistula. 

Diagnosis. — In  children  that  survive  birth  no  urine  is  found 
in  the  diapers,  and  on  examination  there  is  atresia  of  the  urethra 
and  distension  of  the  bladder. 

The  anterior  part  of  the  urethra  may  be  normal,  but  on  pass- 
ing a  fine  bougie  it  is  arrested. 

There  is  no  distension  when  the  urine  can  escape  from  the 
umbilicus  or  into  the  bowel.  In  the  latter  event  urine  is  passed 
with  a  motion  from  the  rectum. 

In  the  majority  of  cases  the  child  is  stillborn,  or  dies  soon  after 
birth.  In  a  few,  when  the  urine  can  escape,  life  is  prolonged  for 
a  few  years,  but  death  takes  place  from  ascending  infection. 

Treatment. ^ — When  atresia  of  the  glandular  urethra  only  is  pre- 
sent the  dilated  portion  of  the  canal  behind  this  may  be  opened 
and  a  penile  fistula  estabhshed,  a  plastic  operation  being  carried 
out  later  for  the  formation  of  a  glandular  urethra.  In  some  cases 
the  glans  has  been  tunnelled  with  a  trocar,  and  the  canal  kept 
open  by  the  passage  of  catheters  or  bougies.  When  the  obliter- 
ated portion  lies  deeper,  the  urethra  may  be  opened  from  the 
perineum  behind  the  obstruction,  and  the  bladder  drained,  a  com- 
munication between  the  posterior  and  anterior  portions  of  the 
urethra  being  established.  Recontraction  of  the  new  canal  does 
not,  apparently,  follow  in  all  cases,  as  might  be  expected,  but  every 
precaution  should  be  taken  to  prevent  this  happening.  Supra- 
pubic puncture  and  cystotomy  are  emergency  operations  to  relieve 
distension. 

DOUBLE  URETHRA  AND  ACCESSORY  TRACKS  OF 
THE  PENIS 

Double  urethra  is  a  very  rare  condition,  and  may  be  com- 
bined with  double  penis,  double  scrotum,  double  bladder,  atresia 
ani,  or  other  congenital  malformations. 

The  second  urethra  may  open  on  the  perineum  or  in  the 
inguinal   region.     A   more   frequent   condition   is   where   a    canal 


XLIV] 


DOUBLE    URETHRA 


571 


opens  on  the  glans  or  below  the  penis,  and  runs  backwards  on 
the  upper  or  under  surface  of  the  penis.  Burckhardt  has  col- 
lected 22  such  cases,  in  18  of  which  the  abnormal  canal  ran  parallel 
with  the  urethra  and  opened  on  the  dorsal  surface  of  the  penis 
in  the  sulcus  coronarius  or  farther  back,  and  in  only  4  did  the 
canal  open  on  the  ventral  surface  of  the  organ.  Rarely  the  glans 
penis  is  split.  The  track  varies  in  length  from  J-5|  in.,  and 
usually  ends  blindly  either  at  the  base  of  the  glans  penis  or  at 
some  part  of  the  penis,  but  occasionally  it  passes  back  to  the 
triangular  ligament,  and  even  pierces  this, 
and  ends  behind  the  pubic  bones.  In  a  few 
cases  the  abnormal  canal  joins  the  urethra, 
and  rarely  it  passes  back  into  the  bladder. 
The  accessory  canal  is  usually  single,  but 
it  may  be  branched.  It  is  lined  with 
squamous  epithelium,  and  occasionally  the 
deeper  part  is  lined  with  columnar  epithe- 
lium. 

A  double  urethra,  either  uniting  or  open- 
ing separately  into  the  bladder,  has  been 
described  in  the  female  subject. 

When  the  second  canal  communicates 
with  the  urethra  or  bladder,  urine  escapes 
from  both  orifices.  Poisson  mentions  that 
the  penis  may  swing  from  side  to  side  dur- 
ing micturition. 

In  gonorrhceal  infection  there  is  dis- 
charge from  both  orifices.     In   a   case  that 


Fig.  179.— Double 
urethra. 


came  under  my  care  (Fig.  179)  a  blind  canal.  Dotted  lines  show  position 
21  in.  in  length  and  admitting  a  No.  7  Fr.  ^^^t' rJ'ln"  a^u^anrel' 
bougie,  opened  on  the  dorsum  of  the  glans  tended  backwards  for  2i  in. 
penis  above  the  meatus.  The  patient  con- 
tracted a  gonorrhceal  infection  of  the  abnormal  canal,  but  the 
urethra  escaped  infection. 

Treatment. — Operation  becomes  necessary  when  the  abnormal 
canal  is  the  seat  of  chronic  inflammation,  which  is  usually  intract- 
able. The  track  may  be  laid  open  in  its  entire  length,  and  the 
lining  membrane  destroyed  with  the  electric  cautery.  Healing 
takes  place  by  granulation,  and  a  thick  scar  may  result,  which 
interferes  with  erection.  Extirpation  of  the  unopened  track  by 
dissection  is  more  difficult,  but  the  after-result  is  better  and  the 
convalescence  quicker. 

If  the  canal  lies  immediately  above  the  normal  urethra  it  may 
be  laid  open  into  it  with  scissors. 


572  THE   URETHRA  [chap. 

CONGENITAL  NARROWING   OF   THE  URETHRA 

The  points  most  frequently  afiected  are  the  external  meatus, 
the  junction  of  the  fossa  navicularis  and  the  penile  urethra,  or  some 
part  of  the  membranous  or  the  prostatic  urethra.  Narrowing  of 
the  external  meatus  is  the  most  common  of  these. 

All  grades  may  be  observed,  to  an  opening  the  size  of  a  pin- 
hole. A  probe  passed  through  the  opening,  and  held  vertically 
so  that  the  point  is  on  the  floor  of  the  fossa  navicularis  and  hooked 
forwards,  will  show  the  extent  of  the  narrowing. 

In  rare  cases  there  is  a  stenosis  of  the  meatus  extending  into 
the  fossa  navicularis.  At  the  junction  of  the  fossa  navicularis 
and  penile  urethra  the  fold  of  Guerin  forms  a  narrowing  in  the 
normal  urethra.  At  this  spot  stenosis  may  be  found,  and  this 
may  be  continued  with  one  or  several  narrowings  of  the  penile 
urethra.  At  the  opening  of  the  membranous  urethra  into  the 
bulb,  and  at  the  junction  with  the  prostatic  urethra,  annular 
contraction,  folds  and  valves  are  found,  and  these  may  occasion- 
ally be  found  between  the  verumontanum  and  the  internal  meatus. 
These  folds  are  concave  towards  the  bladder,  and  give  rise  to 
pronounced  obstruction  to  the  flow  of  urine.  Valve-like  narrow- 
ings are  also  found  in  the  bulbous  urethra. 

Symptoms. — The  symptoms  are  those  either  of  obstruction  to 
the  outflow  of  urine  or  of  interference  with  the  secretion.  Burck- 
hardt  points  out  that  the  more  centrally  the  obstruction  is  situated 
the  earlier  are  symptoms  of  interference  with  the  secreting  ap- 
paratus found ;  the  more  peripheral  the  obstruction,  the  more 
prominent  are  the  symptoms  of  mechanical  obstruction,  while 
changes  in  the  quality  of  the  urine  are  delayed. 

The  symptoms  of  obstruction  are  those  of  a  stricture.  In  severe 
grades,  when  the  obstruction  is  in  the  membranous  or  prostatic 
urethra,  there  is  dilatation  of  the  urethra  behind  the  narrow  point, 
dilatation  of  the  bladder,  ureters,  renal  pelvis,  and  kidney.  There 
is  usually  dribbling  of  urine,  and,  later,  infection  is  superadded. 

Diagnosis. — Stenosis  of  the  meatus  is  readily  seen.  Deeper 
valves  or  folds  may  be  discovered  with  the  sound  or  in  the  adult 
urethra  with  the  urethroscope.  Not  infrequently  a  valve  which 
causes  obstruction  to  the  outflow  of  urine  does  not  interfere  with 
the  introduction  of  an  instrument.  In  adults  the  dilated  portion 
of  the  urethra  behind  the  stenosis  may  be  seen  or  felt.  In  making 
a  diagnosis  of  congenital  stricture  in  children  the  possibility  of 
gonorrhoea  or  traumatism  at  an  early  age  must  be  remembered. 

Treatment. — Stenosis  of  the  meatus  is  treated  by  meatotomy, 
A  general  anaesthetic  may  be  given,  but  local  anaesthesia  usually 


xLiv]  HYPOSPADIAS  573 

suffices.  The  meatus  is  split  downwards  from  within  the  urethra, 
and  two  or  three  catgut  sutures  are  introduced  to  bring  the  mucous 
membrane  of  the  urethra  and  the  skin  together.  If  this  is  not 
done  the  wound  will  heal  rapidly,  leaving  the  stenosis  as  narrow 
as  before. 

In  deeply  situated  stenosis  dilatation  with  graduated  bougies 
should  be  tried,  and,  that  failing,  external  urethrotomy  with 
division  of  the  stricture,  followed  by  the  regular  passage  of 
instruments.  When  the  bladder,  ureter,  and  kidneys  are  dilated, 
surgical  interference  is  unavailing. 

CONGENITAL  DILATATION  OF  THE  URETHRA 

This  condition  is  independent  of  stenosis  of  the  urethra.  The 
dilatation  affects  the  under  surface  of  the  penile  urethra ;  very 
rarely  there  is  dilatation  of  the  bulbous  urethra,  and  the  swelling 
appears  in  the  perineum.  Lawson  Tait  recorded  five  cases  of 
congenital  diverticulum  of  the  female  urethra.     {See  also  p.  586.) 

The  communication  between  the  urethra  and  the  diverticulum 
may  be  very  small,  or  there  may  be  a  large  opening. 

Symptoms  may  appear  soon  after  birth,  or  may  be  delayed. 
There  is  frequent  micturition,  with  a  poor  stream,  pain  during  the 
act,  and  after-dribbling.  Incontinence  is  a  later  result.  A  swell- 
ing on  the  under  surface  of  the  penis  appears  during  micturition. 
The  stream  may  dribble  after  the  diverticulum  has  become  dis- 
tended, and  the  penis  is  sometimes  twisted  to  one  or  other  side 
or  becomes  erect.  The  sac  is  usually  only  partly  emptied  at  the 
end  of  micturition,  and  after-dribbhng  follows. 

Treatment. — The  sac  should  be  excised,  the  urethra  repaired, 
and  the  skin  stitched  separately.  A  catheter  is  tied  in  after  the 
operation.  Should  a  fistula  result,  a  second  operation  is  performed 
for  its  closure,  and  temporary  suprapubic  drainage  of  the  urine 
may  become  necessary  to  allow  the  wound  to  heal  firmly. 

HYPOSPADIAS 

In  hypospadias  (Fig.  180)  the  external  meatus  is  situated  at 
some  point  on  the  under  surface  of  the  penis  or  on  the  perineum. 
Three  grades  are  described,  in  the  following  order  of  frequency : 

1.  Hypospadia  glandis. 

2.  Hypospadia  penis. 

3.  Hypospadia  perinealis. 

Hypospadias  is  the  most  frequent  congenital  malformation  of 
the  urethra.  Mayo  found  1  case  in  350  men,  and  Burckhardt 
22  cases  in  1,849  male  patients. 


574  THE  URETHRA  [chap. 

Etiology. — There  is  no  exact  knowledge  of  the  origin  of  the 
malformation,  but  two  theories  are  advanced.  According  to  one, 
the  lateral  ridges  on  the  under  surface  of  the  genital  tubercle  fail 
to  close  over  the  ventral  groove.  By  the  second  theory,  the  hypo- 
spadias is  due  to  scarring  of  the  urethra,  followed  by  rupture  ; 
and  this  explains  the  scar  tissue  and  pigmentation  round  the 
abnormal  meatus  and  the  bent  form  of  the  penis. 


Fig.  180. — Hypospadias,  showing  downward  curvation  of 
penis  and  apron-like  prepuce.    {See  also  Fig.  181.) 

The  different  degrees  of  hypospadias  closely  correspond  to  the 
stages  of  development  of  the  urethra  {see  p.  392),  and  it  seems 
certain  that  the  condition  results  from  an  arrest  of  development, 
due  perhaps,  as  Hunter  believed,  to  some  imperfection  in  the 
development  of  the  testicles.  In  the  shght  degrees  of  urethral 
and  penile  malformation  these  organs  are  functional,  but  in  the 
severe  grades  (gyneecoid  males)  the  testes  are  imperfect. 

Heredity  is  an  important  factor.  Lesser  found  eleven  cases  of 
hypospadias  in  one  family.     These  were  confined  to  the  second 


xLiv]  HYPOSPADIAS  575 

and  fourth  generations,  while  the  third  and  fifth  generations  were 
free. 

Artificial  hypospadias  is  the  result  of  accident  or  operation, 
and  will  be  described  under  the  heading  of  acquired  defects  of 
the  urethra  (p.  651). 

Pathologfical  anatomy. — 1.  Hypospadia  glandis  is  the  most 
frequent  form  and  the  lowest  grade  of  hypospadias.  Burckhardt 
found  16  cases  of  this  degree  in  22  cases  of  hypospadias. 

The  opening  of  the  urethra  is  situated  on  the  under  surface 
of  the  glans,  or  at  its  junction  with  the  body  of  the  penis,  and 
is  frequently  hidden  by  a  fold  of  skin  under  the  bent  glans. 
Phimosis  may  exist  with  this  degree  of  hypospadias.  The 
meatus  is  a  small  transverse  slit,  or  it  may  be  contracted  to  a 
small  round  opening.  Rarely  there  is  complete  atresia  of  the 
urethra. 

There  is  not  infrequently  scarring  and  pigmentation  round 
the  orifice,  which  is  hard  and  rigid,  and  this  may  extend  for  a 
short  distance  along  the  urethra  and  give  rise  to  urinary  obstruc- 
tion. The  under  surface  of  the  glans  penis  is  split,  and  the  fissure 
varies  in  depth.  With  the  two  sides  in  apposition,  the  external 
meatus  appears  to  be  in  the  normal  position.  On  separating  them 
a  deep  fissure  lined  with  mucous  membrane  is  opened.  This 
corresponds  to  the  sides  and  roof  of  the  fossa  navicularis.  The 
groove  may  be  shallow  and  open.  Opening  at  the  bottom  of  the 
groove  are  one  or  several  lacunae,  varying  in  depth.  A  single 
lacuna  may  be  half  an  inch  or  more  in  depth,  and  it  may  be  diffi- 
cult to  distinguish  the  true  urethral  opening  without  sounding. 
It  is  always  the  lowest  opening.  Usually  the  lacunae,  when  several 
are  present,  are  arranged  in  a  line  at  the  bottom  of  the  groove, 
and  do  not  lie  beyond  the  point  which  would  represent  the  meatus 
were  the  urethra  normal.  Rarely  a  lacuna  in  the  sinus  opens  on 
the  dorsum  of  the  glans. 

In  a  second  form  of  hypospadia  glandis  (Fig.  181)  the  glan- 
dular urethra  is  normally  formed,  but  there  is  a  defect  at  the 
base  of  the  glans,  and  the  urine  is  discharged  from  the  meatus  in 
this  situation.  In  a  third  variety  there  is  a  depression  at  the  end 
of  the  glans,  but  no  groove  or  canal  has  formed  which  would  cor- 
respond to  the  glans  urethrse.  The  foreskin  is  represented  by  a 
fold  at  the  base  of  the  glans  on  the  dorsal  and  lateral  surfaces. 
The  glans  is  usually  bent  downwards,  and  the  shaft  of  the  penis 
may  also  be  curved  towards  the  scrotum,  and  may  be  adherent 
to  it  either  by  a  narrow  fold  or  a  broad  band.  The  median  raphe 
on  the  under  surface  of  the  penis  is  frequently  displaced  to  the 
right  or  the  left. 


576  THE   URETHRA  [chap. 

Undescended  testis,  hernia,  and  other  malformations  may 
compHcate  hypospadias. 

2.  In  hypospadia  penis  (Fig.  182)  the  meatus  lies  on  the  under 
surface  of  the  penile  urethra,  or  at  the  peno-scrotal  junction ;  and 
there  is  a  long  area,  traversed  by  an  open  channel  or  groove,  or 
sometimes  by  a  smooth  surface  level  with  the  rest  of  the  skin.  The 
openings  of  lacunae  on  this  may  be  numerous.  The  penis  may  be 
normal  in  size,  but  a  diminutive  curved  organ  is  frequent  with 
this   degree   of   hypospadias.      The   glandular  urethra,    which   is 


Fig.  181. — Glandular  and  partial  penile  hypospadias. 

View  of  under  surface  of  penis.     (^See  also  Fig.  180.) 

developed  independently  of  the  penile  urethra,  may  be  normal, 
and  open  at  the  normal  meatus  and  at  the  base  of  the  glans. 

3.  Hy3)0spadia  perinealis  is  the  rarest  form.  The  scrotum  is 
split,  and  the  urethra  opens  between  the  halves  or  in  the  perineum. 
When  the  penis  is  rudimentary,  the  two  portions  of  the  scrotum 
poorly  developed,  and  the  testicles  ectopic,  the  external  genitals 
may  resemble  those  of  the  female,  and  the  sex  may  be  mistaken 
until  puberty. 

A  form  of  hypospadias  has  been  described  in  the  female  sub- 
ject in  which  the  part  of  the  urethra  is  split  on  its  vaginal  aspect 
and  the  meatus  opens  within  the  vaginal  orifice. 


XLIV] 


HYPOSPADIAS:    TREATMENT 


577 


Symptoms. — Narrowing  of  the  abnormal  meatus  frequently 
produces  a  fine  or  twisted  stream,  or  this  severe  obstruction  causes 
difficult  micturition.  In  perineal  hypospadias  urine  must  be  passed 
in  the  sitting  posture. 

Normal  coitus  is  possible  in  all  but  cases  where  the  penis  is 
acutely  bent  and  adherent  to  the  scrotum.  When  the  urethral 
orifice  is  situated  far  back  on  the  penis  the  probability  of  impreg- 


Fig.  182. — Penile  hypospadias,  with  completed  glandular 

urethra. 

The  anterior  and  posterior  openings  of  the  glandular  urethra  are  seen.     The  urinary  meatus 
is  at  the  peno-scrotal  junction. 

nation  is  small.     Gonorrhceal  infection  takes  place  more  readily  in 
glandular  hypospadias  than  in  the  normal  urethra. 

Treatment. — Treatment  may  become  necessary  on  account  of 
narrowing  of  the  orifice  of  the  urethra,  for  cosmetic  reasons,  or 
with  the  view  to  ensuring  fertility.  For  the  first,  dilatation  or 
meatotomy  may  be  sufficient,  but  usually,  if  any  operative  inter- 
ference is  necessary,  a  more  complete  restoration  to  the  normal 
state  is  desired.  In  partial  or  complete  glandular  hypospadias  the 
probability  of  a  fruitful  marriage  is  slightly,  if  at  all,  reduced. 


578  THE   URETHRA  [chap. 

but  at  the  same  time  repair  of  the  defect  is  a  simpler  and  more 
certain  procedure  than  in  the  more  extensive  malformations  pre- 
sent in  penile  and  perineal  hypospadias,  where  lack  of  fecundity 
is  practically  certain. 

In  22  cases  observed  by  Burckhardt  there  were  14  married 
men,  of  whom  8  had  children. 

The  operation,  apart  from  the  relief  of  obstruction  occasion- 


Fig.  183. — Use  of  foreskin  to  cover  urethral  defect  in 
glandular  hypospadias. 

The  glans  penis  is  drawn  through  a  slit  in  the  dorsum  of  the  foreskin. 

ally  necessary,  should  not  be  performed  until  the  child  has  reached 
the  age  of  8  or  10  years.  Before  that  age  the  penis  is  small,  and 
the  tissues  are  thin  and  very  delicate,,  and  operation  is  almost 
certainly  attended  by  failure  from  sloughing.  Moreover,  a  second 
operation  is  less  likely  to  be  successful  from  the  scar  tissue 
produced. 

In  all    plastic  operations  on  the  urethra  the   bladder  should 


xLiv]        OPERATIONS  FOR   HYPOSPADIAS 


579 


be  opened  suprapubically  and  drained  for  a  fortnight  after  the 
operation. 

1.  Operations  for  glandular  hypospadias.  (a)  Beckys 
operation. — After  introducing  a  sound  into  the  urethra  a  circular 
incision  is  made  round  the  external  meatus,  leaving  a  collar  of 
skin  round  the  actual  opening,  and  the  incision  is  prolonged  later- 
ally on  each  side  and  extends  to  one-third  of  the  entire  circumfer- 
ence of  the  organ.  A  longitudinal  median  incision  is  made  from 
this  on  the  ventral  svirface  of  the  penis  for  two-thirds  of  the  length 
of  the  organ,  and  the  urethra  dissected  up  for  a  sufficient  distance 
to  allow  of  the  necessary  elongation.  A  flap  of  skin  is  dissected 
back  on  each  side.  If  no  groove  is  present  the  glans  is  penetrated 
longitudinally  with  a  fine  scalpel  and  the  isolated  urethra  drawn 
through  this  canal,  stitched  in  position,  and  the  skin  flaps  united 
on  the  ventral  surface  of  the  penis.     If  a  groove  is  present  the 


Fig.  184. — Flap  operation  for  glandular  hypospadias. 

mucous  lining  is  dissected  out  and  the  urethra  laid  along  the  raw 
■surface.     There  is  a  danger  of  the  isolated  urethra  sloughing. 

(b)  The  use  of  the  redundant  dorsal  prepuce,  as  shown  in  Fig. 
183.  The  hooded  prepuce  is  put  on  the  stretch  and  a  transverse 
buttonhole  opening  made  in  it  near  the  corona  glandis.  Through 
this  the  glans  penis  is  delivered  so  that  the  prepuce  forms  an 
apron  below  it.  A  small  rubber  catheter  is  laid  in  the  groove 
on  the  under  surface  of  the  glans,  and  a  longitudinal  incision 
made  on  each  side  of  this,  and  two  corresponding  longitudinal 
incisions  on  the  anterior  surface  of  the  preputial  apron.  These 
raw  surfaces  are  then  approximated  on  each  side  of  the  catheter 
so  that  the  floor  of  the  urethra  is  formed  by  the  anterior  surface 
of  the  prepuce  between  the  longitudinal  incisions,  and  held  in 
position  by  stitches.  The  fistula  at  the  posterior  edge  of  the  pre- 
putial apron  and  the  abnormal  meatus  is  carefully  repaired.  The 
new  meatus  is  carefully  finished  with  additional  stitches. 

(c)  The  formation  of  skin  flaps  (Fig.  184).  A  longitudinal  skin 
flap,  with  its  base  at  the  abnormal  meatus,  is  raised  from  the  under 


580  THE   URETHRA  [chap. 

surface  of  the  penis.  A  longitudinal  shutter-like  flap,  hinged  at 
its  margin  parallel  to  and  farthest  away  from  the  gutter  under  the 
glans,  is  raised  on  each  side.  The  first  flap  is  turned  forwards  and 
stitched  down,  and  then  covered  by  the  lateral  flaps. 

2.  Operations  for  penile  hypospadias. — The  operation  will 
usually  be  divided  into  two  stages,  and  the  whole  period  covered 
by  the  necessary  operative  measures  may  extend  over  a  year  or 
eighteen  months. 

The  first  stage  consists  in  releasing  the  bands  which  hold  the 
penis  bent  downwards.  These  usually  consist  of  skin  and  fibrous 
tissue  in  the  median  line,  but  the  corpus  spongiosum  may  also 
be  contracted.  After  putting  the  penis  on  the  stretch  these  bands 
are  divided  transversely,  and  the  skin  either  united  transversely 
or  the  raw  area  skin-grafted.  In  order  to  prevent  recontraction 
during  healing,  Burghard  recommends  that  the  penis  be  laid  on 
the  anterior  abdominal  wall  and  secured  there  by  two  stitches, 
a  layer  of  boric  lint  being  interposed  between  the  skin  surfaces. 
A  rubber  catheter  is  placed  in  the  urethra. 

For  the  formation  of  a  penile  urethra  many  operations  have 
been  introduced.  That  of  Duplay  is  well  known.  Bucknall's 
and  Russell's  operations  are  easier  and  more  successful. 

(a)  In  Bwplaifs  operation  a  catheter  is  laid  along  the  ventral 
groove,  and  a  longitudinal  incision  made  on  each  side  and  parallel 
to  it.  Two  longitudinal  flaps  are  raised  and  united  across  the 
catheter,  and  these  again  are  covered  by  flaps  obtained  by  under- 
cutting the  skin  beyond.  There  is  a  great  tendency  to  sloughing 
and  tearing  of  the  sutures,  as  there  is  usually  a  good  deal  of  tension. 

(b)  BucknalVs  o'peration  (Fig.  185)  consists  in  forming  a  floor  for 
the  urethra  from  the  scrotal  skin.  The  abnormally  placed  orifice 
is  the  centre,  and  two  parallel  incisions  are  made  in  front  of  this 
on  each  side  of  the  ventral  groove,  and  carried  an  equal  distance 
beyond  the  meatus  backwards,  on  to  the  skin  of  the  scrotum. 
The  roof  and  floor  of  the  new  urethra  are  then  marked  out. 
Longitudinal  lateral  flaps  are  raised  for  the  whole  length  of  these 
incisions  by  dissecting  outwards.  These  are  turned  outwards 
and  the  penis  laid  down  over  a  small  rubber  catheter,  so  that  the 
isolated  penile  groove  lies  upon  it  and  the  isolated  strip  of  scrotal 
skin  beneath  it.  The  raw  surfaces  of  the  lateral  penile  and  scrotal 
flaps  are  now  in  contact,  and  these  are  stitched  together  with  a 
double  row  of  sutures,  the  first  row  uniting  the  edges  of  the  new 
urethra,  and  the  second  the  redundant  skin  along  the  outer  edge  of 
the  penile  and  scrotal  wounds.  After  a  week,  incisions  are  made 
m  the  skin  of  the  scrotum  parallel  to  the  penis  and  wide  of  it, 
so  that  two  lateral  flaps  are  raised  which  adhere  to  the  lateral 


xLivJ        OPERATIONS  FOR  HYPOSPADIAS 


581 


borders  of  the  penis  when  the  organ  is  dissected  ofi  the  scrotum. 
These  flaps  are  now  united  on  the  ventral  surface  of  the  raised 
penis,  and  the  skin  of  the  scrotum  brought  together.  Burghard 
recommends  that  these  scrotal  flaps  be  made  very  wide,  as  there 
may  be  difficulty  in  uniting  them  round  the  penis.  He  records  three 
successful  cases. 


Fig.  185. — Bucknall's  operation  for  penile  hypospadias. 

A,  Lines  of  incision.     B,  Lateral  flaps  turned  up.     C,  Penis  laid  on  scrotum  with  penile  and 

scrotal  flaps  approximated  by  interrupted  sutures  tied  over  a  rubber  tube  ;    dotted  lines  show 

outline  of  final  scrotal  flap.     D,  Details  of  sutures.     E,  Penis  dissected  off  scrotum  with  final 

scrotal  flaps  approximated. 

(c)  Hamilton  RusselVs  ''stole'"  operation  (Fig.  186).  First  opera- 
tion.— Step  1  :  Incision  through  the  frsenum  which  binds  down  the 
penis.  This  is  carried  round  the  dorsum,  dividing  the  prepuce  near 
the  corona.     The  penis  is  straightened  by  cutting  all  tense  bands. 


582 


THE  URETHRA 


[chap. 


Step  2  :  Glans  tunnelled  with  tenotomy  knife.  Step  3  :  Incision 
as  in  dotted  lines  h,  h  (Fig.  186,  a,  b).  A  strip''of  prepuce  like  a 
clergyman's  stole  is  thus  marked  out.  This  is  detached,  except  at  its 
base,  and  slipped  over  the  end  of  the  penis.  The  end  is  manipulated 
into  a  skin-lined  tube  and  pulled  through  the  tunnel  in  the  glans 
and  there  fixed.  Step  4  :  Suturing  of  flaps  as  in  Fig.  186,  c.  Second 
operation. — Suprapubic  cystotomy  and  closing  of  perineal  urethra. 
3.  Operation  for  perineal  hypospadias. — Monsarrat  raises  a 
large  flap  from  the  scrotum  below  the  orifice  of  the  urethra  and 


Fig.  186. — Hamilton  Russell's  "  stole "  operation  for  perineal 

hypospadias. 

A,  Under  surface  of  penis  showing  («)  raw  area  made  by  first  incision,  (/',  /')  line  of  second  inci- 
sion, ('/)  opening  of  tunnel  through  glans  {i^,  c)  flaps  which  will  form  the  tails  ot  the  stole  and  will 
be  approximated  (arrows)  in  the  middle  line.  B,  Dorsum  of  penis  showing  («,  «)  first  incision, 
(''',  ^')  second  incision,  (c)  dorsal  portion  of  the  stole.  C,  (c)  Dorsal  portion  of  stole,  pulled 
through  tunnel  in  glans  ;  stitching  shown.     D,  First  operation  completed. 

wraps  it  round  a  catheter,  and  sinks  this  into  a  groove  cut  on  the 
ventral  surface  of  the  penis  over  which  he  sutures  the  skin. 

EPISPADIAS 

The  opening  of  the  urethra  is  on  the  dorsum  of  the  penis.  The 
condition  is  very  rare.     Three  grades  are  described  : 

1.  Epispadia  glandis. 

2.  Epispadia  penis. 

3.  Epispadia  totalis. 

The  third  form  is  complicated  with  ectopia  vesicae,  and  is 
referred  to  under  that  head. 

The  following  theories  are  advanced  to  explain  the  malforma- 
tion :    Rupture  of  the  urethra  resulting  from  obstruction  after 


xLiv]  EPISPADIAS  583 

the  bladder  and  urethra  have  closed.  This  takes  place  in  the 
fourth  to  sixth  week  of  foetal  life,  before  the  corpora  cavernosa 
have  united,  so  that  these  bodies  unite  underneath  instead  of 
above  the  uro-genital  sinus.  According  to  Kaufmann,  there  are 
obstruction  at  the  glans  and  gradual  distension  of  the  urethra 
and  rupture,  which  may  take  place  on  the  ventral  surface  (hypo- 
S2)adias)  or  on  the  dorsal  sui'face  (epispadias)  of  the  urethra. 

Pathological  anatomy. — Glandular  epispadias  is  the  rarest 
form.  There  may  be  slight  torsion  of  the  penis.  The  foreskin 
and  fraenum  are  normal.  In  penile  epispadias  the  urethral  orifice, 
which  is  usually  dilated,  is  situated  at  the  symphysis,  and  is  usually 
concealed  beneath  a  fold  of  skin.  On  the  dorsum  of  the  penis  is 
a  broad  groove  lined  wth  pale  mucous  membrane,  which  may 
become  deeper  at  the  glans.  The  penis  is  small,  the  corpora 
cavernosa  are  distorted  and  frequently  separated,  and  the  corpus 
spongiosum  may  lie  on  or  between  the  corpora  cavernosa. 

The  penis  may  be  curved  upwards  and  twisted,  usually  to  the 
left.  The  foreskin  is  split,  and  hangs  like  an  apron  below  the 
glans.  Other  malformations,  such  as  ectopia  testis,  absence  of 
the  prostate,  and  hernia,  may  be  present. 

Epispadias  has  been  described  in  the  female,  the  urethra 
opening  above  the  clitoris. 

Symptoms. — In  glandular  epispadias  there  is  no  interference 
with  the  urinary  function,  but  in  penile  epispadias  incontinence 
of  urine  due  to  imperfect  development  of  the  sphincter  muscle 
is  common.  The  incontinence  may  be  only  on  standing  and  walk- 
ing, but  in  more  severe  cases  it  is  constant.  Eczema  of  the  skin 
is  common.  In  slight  grades  there  is  no  interference  with  the 
sexual  function,  but  in  severe  grades  reproduction  is  impossible. 

Treatment. — The  penis  should  first  be  straightened  by 
section  of  bands  and  adhesions. 

A  necessary  preliminary  to  a  plastic  operation  is  perineal 
drainage  of  the  bladder,  w^hich  is  maintained  during  the  healing 
of  the  wounds. 

Duflai/s  operation  consists  in  freshening  the  edges  of  the  dorsal 
groove  and  bringing  them  together  over  a  catheter. 

Thiersch's  operation  consists  in  (1)  turning  a  longitudinal  flap 
from  one  side  of  the  groove  over  a  catheter  and  covering  the  outer 
raw  surface  of  this  with  a  second  flap  from  the  other  side  ;  (2) 
repairing  the  groove  in  the  glans  and  removing  the  apron-like  fore- 
skin ;  (3)  turning  do\\m  a  flap  from  the  pubic  region  to  cover  the 
fistula  which  remains  at  the  base  of  the  penis.  The  patient  may 
become  continent  after  the  operation,  but  not  infrequently  incon- 
tinence continues,  and  an  apparatus  must  be  worn. 


584  THE    URETHRA  [chap,  lxiv 

LITERATURE 

Allen,  Boston  Med.  and  Surg.   Journ.,  April  3,  1902. 

Bazy,  Presse  Med.,  1903,  p.  215. 

Beck,  N.Y.  Med.  Journ.,  Jan.  29,  1908,  and  Dec.  8,  1900. 

Bucknall,  Lancet,  Sept.  28,  1907,  vol.  ii. 

Burekhardt,   E.,    Handbuch  der  Urologie   (von  Frisch   und  Zuckerkandl),    1906, 

vol.  iii. 
Burghard,  F.,  System  of  Operative  Surgery,  1909,  vol.  iii. 
Dubot,  Ann.  d.  Mai.  d.  Org.  Gen.-Vrin.,  1902,  No.  1. 
Edington,  Brit.  Med.   Journ.,  Sept.  21,  1907. 
Ehrlich,   Beitr.  z.  klin.    Chir.,  1908,  p.   193. 
Englisch,   Wien.  med.   Woch.,  1889,  p.  1513  ;    Centralhl.  f.  d.  Krankh.  d.  Ham-  u. 

Sex.-Org.,Yi.  169. 
Escat,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1908,  p.  1. 
Fleischmann,  Morph.  Jahrb.,  1904,  p.  23. 
Gutmann,  Zeits.  f.  Urol,  1910,  p.  575. 
Kaufmann,  Deuts.  Chir.,  1886. 
Keith,  Brit.  Med.  Journ.,  Dec.  19,  1908. 

Lichtenberg,  Ueber  die  BntwicMungsgeschichte  accessorischer  Gdnge  am  Penis,    1906. 
Mayo,  Journ.  of  Amer.  Med.  Assoc,  April,  1901. 
Monsarrat,  Med.  Ann.,  1902,  p.  339. 
Posner,  Berl.  klin.  Woch.,  1907,  p.  375. 
Russell,  Hamilton,  Brit.  Med.  Journ.,  1900,  ii.  1432. 
Waekens,  Zeits.  f.  Urol.,  1910,  p.  814. 


CHAPTER  XLV 
PROLAPSE  OF  THE  URETHRA— URETHROCELE 

PROLAPSE 

This  is  a  rare  condition,  which  occurs  only  in  women  and  female 
children.  About  170  cases  are  on  record.  More  than  half  the  cases 
are  children  (66  per  cent.)  under  15,  and  most  of  the  remaining 
cases  occur  after  the  menopause.  In  total  prolapse  a  ring  of 
mucous  membrane  protrudes  from  the  meatus,  while  in  partial 
prolapse  the  mucous  membrane  of  one  part  of  the  circumference, 
frequently  the  posterior  wall,  is  extruded. 

Etiology. — The  condition  results  from  the  combination  of 
local  conditions  such  as  vulvo-vaginitis,  gonorrhoea,  the  intro- 
duction of  foreign  bodies,  dilatation  of  the  urethra,  tumours  of 
the  urethral  mucous  membrane,  and  the  loss  of  tone  and  elas- 
ticity of  the  urethral  wall  consequent  on  advanced  age. 

Straining  may  be  produced  by  the  urethral  condition,  or  may 
result  from  cystitis,  constipation,  coughing. 

Heredity  may  be  a  predisposing  factor.  The  condition  has 
been  observed  in  mother  and  daughter  and  in  two  sisters. 

Symptoms  and  diagnosis.— The  onset  is  insidious.  There 
are  urethral  irritation  and  discomfort,  and  the  prolapsed  mucous 
membrane  becomes  tender  and  painful  on  sitting.  Difficult  mic- 
turition, strangury,  burning  on  micturition,  and  incontinence  have 
been  observed.     In  old  people  symptoms  may  be  entirely  absent. 

There  is  at  first  a  protrusion  of  a  portion  of  mucous  mem- 
brane, or  a  complete  ring  of  normal  mucous  membrane  appears. 
This  is  easily  replaced,  or  may  even  retract  spontaneously.  The 
prolapse  gradually  increases,  and  may  reach  a  hen's  egg  in  size. 
The  mucous  membrane  becomes  congested,  blue  and  inflamed, 
and  excoriated  or  ulcerated,  and  a  purulent  blood-stained  dis- 
charge soils  the  linen.  On  straining,  the  swelhng  increases  in 
size.  A  sound  introduced  into  the  central  opening  passes  readily 
into  the  bladder.     In  partial  prolapse  the  opening  is  eccentric. 

The  diagnosis  is  made  by  the  position  of  the  swelling  and  the 
opening   of   the   urethra.     The   urethra   should  be   examined  for 

585 


586  THE   URETHRA  [chap. 

polypi  or  other  growths,  and  the  urine  for  evidence  of  cystitis. 
In  prolapse  of  the  bladder  there  is  no  central  opening,  and  the 
lumen  of  the  urethra,  ascertained  by  introducing  a  sound,  sur- 
rounds the  tumour. 

Treatment. — In  slight  cases  the  prolapse  may  be  reduced  and 
the  cause,  such  as  cystitis,  treated.  Longitudinal  searing  with  the 
electric  cautery  is  sometimes  followed  by  contraction  of  the  mucous 
membrane  and  disappearance  of  the  prolapsed  portion.  Several 
applications  are  necessary.  In  more  advanced  cases  the  pro- 
lapsed mucous  membrane  should  be  removed.  A  partial  prolapse 
is  excised  by  an  elliptical  incision,  and  the  cut  edges  of  mucous 
membrane  are  carefully  united.  A  total  prolapse  is  removed  by 
a  circular  incision.  Care  should  be  taken  not  to  drag  down  too 
much  mucous  membrane,  and  as  the  circular  incision  made  by 
scissors  or  knife  proceeds,  fine  catgut  stitches  are  passed  through 
the  mucous  membrane  at  the  upper  edge  of  the  incision  to  prevent 
retracting ;  these  are  used  to  unite  the  upper  and  lower  edges  of 
the  incision  after  the  prolapsed  portion  has  been  removed.  The 
bladder  is  drained  by  a  fixed  catheter. 

LITERATURE 

Bente,  Miinch.  med.  Woch.,  Dec.  31,  1901. 

Glaevecke,  Miinch.  med.  Woch.,  May  28,  1901,  Nr.  22. 

Herman,  Brit.  Med.  Joum.,  1889,  i.  296. 

Kleinwachter,  Zeits.  f.  Geh.  u.  Gyn.,  1891,  Bd.  xxii.  ;    and  1905,  Bd.  xlii. 

Pinkuss,  Berl.  Uin.   Woch.,  1901,  Nr.   19,  21. 

Voillemin,  These  de  Paris,  1900  ;    Brit.  Med.  Joum.,  Nov.  10,  1900. 

Warker,  Amer.  Med.,  1904,  viii.  273. 

URETHROCELE 

A  pouch-like  dilatation  of  the  urethra  occurs  alike  in  male 
and  female  subjects,  and  may  be  either  congenital  {see  p.  573)  or 
acquired.  The  cavity  is  lined  by  mucous  membrane  from  the 
urethra,  which  may,  however,  be  inflamed  and  ulcerated.  The 
muscular  wall  is  present,  but  may  be  represented  by  a  few  fibres 
of  non-striped  muscle,  or  there  may  be  only  cavernous  tissue 
between  the  mucous  surfaces  of  the  sac  and  the  A^agina.  The 
sac  contains  purulent  urine,  and  occasionally  a  calculus. 

These  cases  should  be  distinguished  from  false  urethroceles  in 
which  urine  collects  in  an  abscess  or  other  cavity  outside  the 
urethral  wall  and  communicating  with  the  urethral  lumen.  •  True 
urethrocele  is  rare ;  Burckhardt  collected  altogether  31  cases 
from  the  literature.  The  majority  of  cases  occur  between  the 
ages  of  25  and  45  (74  per  cent.).  There  is  usually  a  history  of 
injury   such   as  occurs  in  instrumental  labour,  passage  of  stones. 


xLv]  URETHROCELE  587 

introduction   of   foreign   bodies,    etc.     Duplav   and   Legueu   hold 

that  it  is  a  form  of  prolapse. 

Symptoms. — Dribbling  after  micturition  is  the  most  frequent 
symptom,  and  this  is  increased  on  standing  up  and  walking. 
Frequent  micturition  is  observed,  and  the  urine  becomes  infected 
and  alkaline,  and  eventually  incontinence  may  be  present  with 
irritation  and  excoriation  of  the  skin. 

There  is  pain  in  coitus,  and  also  in  micturition  and  defsecation, 
and  severe  attacks  of  radiating  pain  in  the  back  and  vomiting 
may  follow.     Neurasthenia  may  eventually  supervene. 

On  examination,  in  the  female  a  rounded  swelling  appears 
on  the  anterior  wall  of  the  vagina  in  the  position  of  the  urethra. 
This  is  covered  with  normal  vaginal  mucous  membrane,  and 
varies  in  size  from  a  hazel-nut  to  a  hen's  egg.  On  pressure  it 
is  tender  and  fluctuating,  and  urine  can  be  expressed  from  the 
external  meatus.  This  is  alkaline  and  ammoniacal,  and  on  pass- 
ing a  catheter  into  the  bladder  clear  or  slightly  turbid  urine  is 
withdrawn.  A  curved  probe  or  stone  sound  can  usually  be 
manipulated  into  the  pouch  and  felt  from  the  vagina. 

Diagnosis. — The  symptoms  seldom  leave  any  doubt  as  to 
the  diagnosis.  Vaginal  cystocele  is  situated  higher  in  the  vagina, 
and  the  urethral  tube  can  be  detected  below  it.  Cystocele  forms 
a  large  swelling,  which  is  emptied  by  catheter,  and  the  urethro- 
scope and  cystoscope  render  the  diagnosis  certain.  Prolapse  of 
the  anterior  vaginal  wall  and  cysts  of  the  vagina  are  not  accom- 
panied by  any  modification  of  the  act  of  micturition,  and  the 
urine  is  normal. 

Treatment. — By  washing  with  solution  of  nitrate  of  silver 
and  weak  antiseptics,  and  application  of  stronger  solutions  of 
nitrate  of  silver  through  the  urethroscope,  the  inflammatory  com- 
plications can  be  cured,  but  the  only  radical  form  of  treatment 
of  the  sac  is  by  operation.  Before  operation  the  sac  must  be 
thoroughly  washed  and  the  bladder  treated,  and  the  vagina  also 
carefully  prepared. 

A  sound  is  placed  in  the  sac  from  the  urethra,  or  the  sac  may 
be  packed  with  gauze  and  dissected  out  and  removed  with  an 
elliptical  area  of  the  anterior  vaginal  wall.  The  urethral  wall  is 
carefully  repaired,  and  then  the  vaginal  wall  accurately  united. 

LITERATURE 

Boursier,  Sem.  Med.,  1895,  p.  379. 

Duplay,  Arch.  Gen.  de.  Med.,  1898,  p.  745. 

Emmet,  N.Y.  Med.   Journ.,  Oct,  27,  1888. 

Lejars,  Sem.  Med.,  July  28,  1908. 

Pouly,   Lijon  Med.,  Feb.  4,  1900. 

Routier,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1896,  p.  189. 


CHAPTEE  XLVI 
INJURIES  OF  THE  URETHRA 

WOUNDS 

The  urethra  may  be  wounded  from  within  as  in  the  passage  of 
instruments,  or  from  without  by  cutting  weapons,  bullets,  etc. 
Injuries  made  by  instruments  from  within  (false  passages)  are 
discussed  elsewhere  (p.  636).  Apart  from  surgical  operations  the 
urethra  is  rarely  wounded  by  cutting  instruments.  The  penile 
urethra  is  usually  affected ;  rarely  a  stab  in  the  perineum 
wounds  the  bulbous  urethra. 

Haemorrhage  is  usually  severe.  A  transverse  wound  of  the 
urethra  gapes,  while  a  longitudinal  wound  does  not.  Where  free 
exit  is  afforded  to  the  urine  no  extravasation  takes  place,  but 
when  the  urethral  wound  does  not  correspond  to  the  skin  wound, 
or  when  the  wound  is  in  the  perineum,  widespread  extravasation 
is  likely  to  occur. 

Bullet  wounds  of  the  urethra  are  rare,  and  more  often  affect 
the  bulbous  than  the  penile.  In  the  American  Civil  War  there 
were  105  cases.  The  urethra  may  be  directly  wounded,  or  it 
may  be  injured  through  splintering  of  the  pelvic  bones. 

Treatment. — Immediate  suture  of  the  urethra  should  be  per- 
formed in  order  to  avoid  extravasation  of  urine  and  subsequent 
stricture.  The  wound  is  opened  up,  a  catheter  passed  along  the 
urethra,  and  the  proximal  and  distal  ends  carefully  sutured  with 
catgut  over  this.  The  corpus  spongiosum  is  then  united,  and  the 
skin  stitched  separately.  A  catheter  should  be  tied  in  the  urethra 
for  four  days. 

The  wound  frequently  heals  by  primary  union,  and  no  stricture 
is  formed.  On  the  other  hand,  if  the  wound  is  infected  and  breaks 
down,  and  heals  by  granulation,  a  thick  scar  forms,  and  a  stricture 
of  the  urethra  develops.  If  suppuration  or  extravasation  has 
already  taken  place  when  the  case  comes  under  observation,  an  at- 
tempt to  bring  the  cut  ends  of  the  urethra  together  should  still  be 
made.  Bullet  wounds  should  be  carefully  cleaned  and  the  urethra 
repaired,    A  catheter  is  tied  in  the  urethra  and  the  wound  drained. 

588 


CHAP.xLvi]  URETHRAL    RUPTURE  589 

In  119  cases  of  gunshot  wounds  of  the  urethra  Kaufmann 
found  a  mortality  of  22  per  cent.,  due  to  septic  complications  and 
extravasation  of  urine. 

RUPTURE   OF   THE  URETHRA 

In  rupture  there  are  several  degrees  of  injury  to  the  urethra, 
and  any  part  of  the  canal  may  be  involved. 

Pathological  anatomy. — In  interstitial  rupture  or  bruising 
of  the  urethra  neither  the  mucous  membrane  nor  the  fibrous 
sheath  of  the  corpus  spongiosum  is  ruptured.  In  partial  rupture 
there  is  rupture  of  the  spongy  tissue  and  either  the  fibrous  sheath 
(partial  external)  or  the  mucous  membrane  (partial  internal).  In 
total  rupture  the  corpus  spongiosum,  the  mucous  membrane,  and 
the  fibrous  sheath  are  all  ruptured. 

The  rupture  is  incomplete  when  a  part  of  the  circumference 
of  the  urethra  is  intact,  and  complete  when  the  whole  circum- 
ference is  ruptured.  The  severed  ends  contract  and  retract  so 
that  they  may  be  widely  separated. 

1.  Rupture  of  the  penile  urethra  is  rare  in  the  flaccid  state, 
but  is  more  frequent  when  the  organ  is  erect.  A  direct  blow 
with  the  fist,  or  a  kick,  is  the  most  frequent  cause.  The  injury 
may  be  indirect,  when  "  fracture  of  the  urethra  "  is  said  to  occur. 
This  may  result  from  twists  during  coitus,  forcible  bending,  or  it 
may  occur  spontaneously  without  external  violence  when  erection 
takes  place  and  the  urethra  is  inflamed,  as  in  chordee  during  gonor- 
rhoea. The  rupture  is  partial  internal,  or  it  may  be  interstitial. 
It  is  never  complete.  The  level  of  the  peno-scrotal  junction  is 
the  seat  of  election. 

2.  Rupture  of  the  bulbous  urethra  is  much  more  frequent.  It 
results  from  a  kick  on  the  perineum,  a  blow  with  a  lever,  a  fall 
astride  a  beam  or  trestle,  or  a  blow  on  the  pommel  of  a  saddle. 
The  rupture  is  usually  complete  and  total,  and  the  severed  ends 
retract  some  distance.  The  position  of  the  rupture  depends  upon 
the  attitude  of  the  body  at  the  time  of  the  injury.  Very  rarely  the 
urethra  has  been  ruptured  in  two  places.  According  to  Ferrillon 
the  cavernous  tissue  surrounding  the  urethra  is  the  least  resistant 
layer,  and  is  always  ruptured  first,  then  the  mucous  membrane, 
and  last  the  fibrous  sheath.  The  urethra  is  crushed  between  the 
injuring  body  and  the  pubic  arch  and  triangular  ligament.  When 
the  direction  of  the  blow  is  lateral  and  the  body  which  produces 
it  small,  the  urethra  is  injured  against  one  limb  of  the  pubic  arch  ; 
when  the  blow  is  median  and  the  injuring  body  large,  the  urethra 
is  injured  against  the  pubic  symphysis  or  the  triangular  ligament, 
according  to  the  direction  of  the  blow.     If  the  force  strikes  the 


590  THE   URETHRA  [chap. 

perineum  in  a  direction  from  before  backwards  the  bulbous  urethra 
is  the  part  injured ;  but  if  the  blow  strikes  the  perineum  from 
behind  forwards  the  membranous  urethra  is  injured. 

3.  Rupture  of  the  membranous  urethra  occurs  in  severe  injuries 
with  fracture  of  the  pelvis  or  dislocation  of  the  pubic  bones.  The 
urethra  is  torn  by  a  fragment  of  the  pubic  ramus,  or  the  triangular 
ligament  may  be  torn.  The  membranous  urethra  is  also  torn  by 
blows  upon  the  buttocks  without  fracture  of  the  pelvis.  Legueu 
and  others  suppose  that  a  temporary  dislocation  of  the  symphysis 
pubis  takes  place,  causing  tearing  of  the  triangular  ligament  and 
rupture  of  the  urethra.  Rupture  of  the  membranous  urethra  is 
complete,  and  the  two  ends  are  separated  and  may  be  much  torn 
by  the  fragments  of  the  fractured  pubic  arch. 

4.  The  prostatic  urethra  is  very  rarely  ruptured. 
Symptoms. — The  symptoms  vary  according  to  the  position 

of  the  injury.  In  rupture  of  the  2^ew^7e  urethra  there  is  haemor- 
rhage from  the  meatus,  severe  at  first,  but  diminishing  and  dis- 
appearing in  a  few  days.  There  is  pain  on  micturition,  but  rarely 
difficulty  or  retention  of  urine.  Extravasation  of  urine  does  not 
occur,  but  stricture  invariably  follows.  In  interstitial  rupture  or 
bruising  external  haemorrhage  is  wanting,  and  there  may  be  no 
symptoms  until  some  months  or  years  later  a  stricture  develops. 

Rupture  of  the  bulbous  urethra  is  the  most  common  form.  After 
a  fall  astride  a  beam  there  is  sharp  perineal  pain,  which  increases 
in  severity  as  effusion  of  blood  proceeds.  Haemorrhage  from  the 
meatus  follows  immediately  on  the  injury,  and  varies  greatly  in 
severity.  It  may  cease  rapidly,  or  it  may  be  abundant  and  con- 
tinuous. A  tumour  rapidly  forms  in  the  perineum.  Some  bruising 
of  the  skin  may  be  present  from  the  injury,  and  there  is  a  romided 
swelling  of  variable  size  over  the  bulbous  urethra.  The  swelling 
is  tense  and  tender,  and  does  not  extend  backwards  beyond  the 
transverse  perineal  muscle,  while  it  is  limited  laterally  by  the 
arch  of  the  pubes.  In  less  severe  cases  the  fibrous  sheath  is  not 
ruptured,  and  the  large  perineal  swelling  does  not  appear.  There 
are  only  haemorrhage,  pain,  and  tenderness  of  the  urethra.  Reten- 
tion of  urine  frequently  follows  the  injury,  but  the  patient  may 
pass  urine  before  he  comes  under  observation. 

Rupture  of  the  membranous  or  prostatic  urethra  is  associated 
with  fracture  of  the  pelvis,  and  attention  may  not  at  first  be  drawn 
to  the  rupture.  (Plate  39,  Fig.  1.)  Haemorrhage  is  slight;  the 
blood  is  effused  round  the  membranous  urethra,  and  finds  its  way 
downwards  to  the  perineum,  so  that  some  days  may  elapse  before 
swelling  or  discoloration  of  the  perineum  appears.  Retention  of 
urine  is  absolute,  and  may  last  several  days  ;   when  urine  is  passed 


Fig.   1. — Pelvic  shadow  after  fracture  of  pelvis  (arrows) 
and  rupture  of  urethra.     (P.  590.) 

Fig.  2. — Stone  in  fossa  navicularis    of  urethra    (arrow). 
(P.  621.) 


Plate  39. 


xLvi]  URETHRAL   RUPTURE  591 

there  is  pain  and  straining,  and  only  a  few  drops  escape  from  the 
urethra.  In  the  rectum  a  tender  swelHng  is  felt  over  the  mem- 
branous or  prostatic  urethra.  The  abdominal  muscles  are  fre- 
quently rigid.  A  distended  bladder  may  be  felt,  or  the  dullness 
percussed,  above  the  pubes. 

In  cases  where  the  rupture  lies  behind  the  compressor  urethrae 
and  triangular  ligament  there  may  be  an  escape  of  blood  from  the 
meatus.  Extravasation  of  blood  and  urine  takes  place  into  the 
areolar  tissue  of  the  pelvis,  and  there  is  rigidity  of  the  abdominal 
muscles  and  increasing  suprapubic  dullness. 

Diagnosis. — In  rupture  of  the  penile  and  bulbous  urethra 
haemorrhage  is  constant  in  all  but  the  interstitial  variety.  This, 
combined  with  local  tenderness  in  penile  rupture  and  swelling 
in  perineal  rupture,  suffices  for  the  diagnosis.  When  a  perineal 
haematoma  is  present  the  rupture  has  affected  the  fibrous  sheath, 
but  it  is  impossible  to  say  whether  the  tube  is  completely  torn 
or  a  bridge  of  mucous  membrane  remains  until  an  operation  has 
been  performed.  If  there  is  no  tumour,  Legueu  advises  that  a 
catheter  be  passed,  and  if  it  glides  easily  into  the  bladder  it  should 
be  tied  in  place.  If  the  catheter  does  not  pass,  operation  should 
be  midertaken.  In  rupture  of  the  posterior  urethra  the  chief 
difficulty  is  in  distinguishing  between  this  and  extraperitoneal 
rupture  of  the  bladder.  On  rectal  examination  there  are  tender- 
ness and  swelling  over  the  membranous  or  prostatic  urethra,  and 
on  examination  of  the  abdomen  the  bladder  is  usually  distended 
in  rupture  of  the  urethra  and  is  collapsed  in  rupture  of  the  bladder. 
On  passing  a  catheter  there  is  difficulty  at  the  membranous  or 
prostatic  urethra,  but  in  rupture  of  the  bladder  the  instrument 
passes  easily  into  the  bladder.  Operation  will  be  required  in 
either  case,  but  the  selection  of  the  suprapubic  or  perineal  route 
will  depend  upon  the  diagnosis. 

Course  and  prognosis. — In  rupture  of  the  'penile  urethra 
the  haemorrhage  rapidly  ceases  and  the  wound  heals,  but  a  stric- 
ture forms  within  a  few  months.  In  the  bulbous  urethra,  if  the 
patient  tries  to  pass  urine  he  may  fail  from  absolute  retention, 
or  he  passes  a  few  drops  with  great  difficulty,  extravasation  of 
urine  into  the  perineum  takes  place,  and  infection  follows.  The 
extravasation  pursues  the  same  course  as  in  stricture  of  the  urethra, 
and  is  accompanied  by  rigors  and  high  temperature,  and  the 
patient  may  succumb  if  operation  is  not  promptly  performed. 
In  less  severe  cases  the  perineal  swelling  breaks  down,  and  urinary 
fistulae  form  in  the  perineum.  In  a  case  of  rupture  of  the  bulbous 
urethra,  in  w^hich  I  passed  a  catheter  and  fixed  it  for  three  days, 
no   extravasation  took  place,   but  some  months  later  a  broken 


592  THE   URETHRA  [chap. 

ring  of  phosphatic  material,  ^  in.  in  thickness,  which  had  formed 
on  the  raw  area,  was  extracted  from  the  urethra.  Stricture  follows 
unoperated  rupture  of  the  urethra  within  a  few  weeks  or  months 
of  the  injury,  and  its  extent  and  density  depend  upon  whether 
suppuration  and  sloughing  took  place,  and  what  distance  separated 
the  severed  ends.  The  development  of  stricture  may  occasionally 
be  delayed,  and  Bazy  has  recorded  a  case  in  which  the  interval 
between  the  injury  and  the  onset  of  symptoms  was  thirty  years. 
Treatment. — In  rupture  of  the  'penile  urethra  the  canal  should 
be  washed  with  hot  weak  solution  of  silver  nitrate,  1  in  10,000. 
Suprarenal  extract,  1  in  1,000,  may  be  introduced  if  the  hsemor- 
rhage  continues,  and  an  ice-bag  applied.  A  catheter  is  passed 
and  fixed  in  position.  The  urethra  should  be  washed  alongside 
this  daily,  and  the  instrument  removed  after  three  or  four  days. 
The  passage  of  metal  instruments  should  be  commenced  after  a 
fortnight  and  continued  regularly. 

In  rupture  of  the  bulbous  urethra  operation  is  necessary.  A 
metal  catheter  is  passed  gently  along  the  urethra,  keeping  to 
the  roof  of  the  canal.  If  it  passes  the  point  of  rupture  and  enters 
the  bladder,  the  urine  is  drawn  ofi  and  the  instrument  kept  in 
position.  If  it  does  not  pass  into  the  bladder  it  should  be  left 
in  the  urethra.  The  patient  is  placed  in  the  lithotomy  position 
and  an  incision  made  into  the  hsematoma.  If,  on  attempting  to 
pass  the  catheter,  the  rupture  be  found  to  lie  deeply  in  the 
membranous  urethra,  a  curved,  transverse,  prerectal  incision  will 
give  the  best  exposure ;  but  when  the  rupture  lies  in  the  bulbous 
urethra  a  median  incision  is  preferable.  The  clots  are  turned  out, 
and  a  stream  of  hot  lotion  from  an  irrigator  is  used  to  stop 
oozing.  If  the  urethra  has  not  been  completely  severed  there  is 
no  difficulty  in  finding  its  torn  edges,  and  a  catheter  is  passed 
along  the  penile  urethra  and  into  the  bladder.  The  edges  of  the 
ruptured  urethra  are  trimmed  and  united  as  accurately  as  possible 
with  catgut  sutures. 

The  bladder  is  now  distended  with  fluid  through  the  catheter, 
and  the  patient  placed  in  the  horizontal  position.  The  bladder  is 
opened  above  the  pubes,  and  a  large  rubber  drain  introduced.  The 
catheter  is  now  removed,  and  the  lower  end  of  the  bed  raised  to 
keep  the  urine  from  contact  with  the  internal  meatus.  A  suction 
apparatus  (p.  547)  may  be  installed  if  considered  necessary.  This 
method  gives  much  better  results  than  drainage  by  urethral 
catheter,  where  the  catheter  acts  as  a  foreign  body  and  causes 
urethritis,  and  after  the  first  few  days  the  urine  commences  to 
trickle  alongside  the  catheter  and  causes  sloughing  of  the  urethral 
wound  and  subsequent  formation  of  dense  scar  tissue. 


xLvi]      URETHRAL  RUPTURE :  TREATMENT       593 

If  the  urethra  has  been  completely  severed  the  penile  end  of 
the  canal  is  readily  found,  and  a  search  for  the  vesical  end  is 
commenced.  Every  depression  should  be  probed  under  a  strong 
light.  The  end  may  be  found  as  a  shred  of  loose  tissue;  it 
may  resemble  the  twisted  end  of  a  large  blood-vessel,  or  it  may 
be  identified  by  the  persistent  bleeding  of  a  small  vessel  in 
its  wall.  Should  a  careful  search  fail  to  reveal  the  stump  of 
the  urethra,  the  gloved  forefinger  of  the  left  hand  should  be  intro- 
duced into  the  rectum,  and  when  placed  at  the  apex  of  the  pros- 
tate will  indicate  the  exact  position  of  the  membranous  urethra. 
Lastly,  pressure  above  the  pubes  will  cause  some  urine  to  trickle 
from  the  over-distended  bladder  and  show  the  position  of  the 
urethral  stump. 

If  the  search  is  successful  the  ends  are  approximated  over 
a  gum-elastic  catheter  and  united  with  catgut  sutures.  In  stitch- 
ing the  urethra  it  is  important  to  put  in  a  continuous  extra- 
mucous  thread  of  fine  catgut  and  support  this  by  uniting  the 
perineum  in  layers.     Suprapubic  drainage  is  now  established. 

If  the  ends  cannot  be  approximated  without  tension  the 
attempt  to  suture  them  must  be  abandoned. 

The  cavity  is  lightly  packed  with  gauze  and  drained,  the 
perineal  muscles  and  skin  are  brought  together,  and  the  catheter 
fixed  in  place.  Suprapubic  drainage  should  now  be  established 
with  a  ^-in.  rubber  drainage  tube,  and  continued  for  a  fortnight. 
The  catheter  and  perineal  drain  are  removed  after  a  few  days. 

Should  the  search  for  the  vesical  end  of  the  urethra  prove 
fruitless,  suprapubic  cystotomy  should  be  performed  and  a  bougie 
passed  along  the  urethra  from  the  bladder.  The  vesical  end  of 
the  urethra  is  now  identified,  and  the  operation  completed  as  before. 
After  healing  of  the  injury,  metal  instruments  should  be  passed  at 
regular  intervals,  commencing  a  fortnight  or  three  weeks  after  the 
operation,  according  to  the  extent  of  the  injury. 

In  rupture  of  the  membranous  or  prostatic  urethra  a  curved 
prerectal  incision  with  the  convexity  forwards  should  be  made, 
and  the  hsematoma  incised.  If  the  vesical  end  of  the  urethra  is 
not  found,  the  bladder  should  be  opened  suprapubically  and  retro- 
grade catheterization  of  the  urethra  performed.  A  catheter  is 
now  passed  from  the  bulbous  portion  into  the  bladder,  and  the 
urethra  miited  over  this.  In  any  case  the  catheter  is  retained, 
the  wound  drained,  and  suprapubic  drainage  of  the  bladder 
established. 

Mortality. — In  uncomplicated  rupture  of  the  urethra  Kauf- 
mann  found  a  mortality  of  14-15  per  cent,  in  205  cases.  Urinary 
infiltration  produced  a  death-rate  of  36  per  cent,  when  it  occurred. 


594  THE   URETHRA  [chap,  xlvi 

Treatment  by  retained  catheter  without  operation  had  a  mor- 
tahty  of  18-17  per  cent.  In  the  latter  cases  only  the  least  exten- 
sive injuries  are  included,  and  the  mortality  is  therefore  very 
high.  In  rupture  of  the  urethra  with  fracture  of  the  pelvis  the 
mortality  in  48  cases  was  40  per  cent. 

In  17  cases,  4  of  which  were  complicated  with  fractured  pelvis, 
the  mortaUty  was  5-7  per  cent.  All  these  cases  were  submitted 
to  perineal  section  and  immediate  suture. 

After-results. — The  formation  of  a  stricture  after  rupture 
of  the  urethra  was  an  almost  invariable  result  in  the  cases  recorded 
by  older  writers.  Where  primary  union  or  rapid  healing  of  the 
urethra  is  obtained,  the  canal  either  remains  uncontracted  or  the 
stricture  which  forms  is  readily  amenable  to  treatment. 

In  7  cases  operated  on  by  Rutherfurd  the  urethra  was   free 

from  stricture  in  5  at  periods  of  sixteen  and  seventeen  months, 

three,  three,  and  six  years  respectively.     In  5  cases  recorded  by 

Cabot  no  stricture  was  present  from  three  to  five  years  after  the 

injury. 

LITERATURE 

Barling,  Birmingham  Med.  Rev.,  1891,  p.  321. 

Birkett,  Lancet,  1866,  ii.  693. 

Cabot,  Boston  Med.  and  Surg.  Journ.,  1896,  p.  57. 

Chambers,  West  London  Med.  Journ.,  1906,  p.  134. 

Jacobson,  N.  Y.  Med.  Journ.,  1900,  p.  799. 

Legueu,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1907,  ii.  1090. 

Lennander,  Arch.  f.  klin.  Chir.,  1897,  p.  484. 

Martens,  Die  Verletzungen  und  Verengerungen  der  Harnrohre.     Berlin,  1902. 

Oberst,    Volkmanns  Samml.  klin.  Vort.,  Nr.  210. 

POUX,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1904,  p.  187. 

Riche,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1904,  p.  1827. 

Rutherfurd,  Glasg.  Hosp.  Repts.,  1898  ;  Lancet,  Sept.  10,  1904. 

Sezcypiorski,  Ann.  d.  Mai.  d.   Org.   Gen.-  Urin.,  1907,  ii.  1033. 

Wasilieu,  Die  Trauman  der  mdnnlichen  Harnrohre.     Berlin,  1900. 


CHAPTER     XL  VII 
URETHRITIS 

The  term  urethritis  is  applied  to  inflammation  of  the  urethra 
arising  from  whatever  cause,  whether  acute  or  chronic,  affecting 
the  whole  or  only  a  part  of  the  canal. 

Bacteriology.- — In  the  male  the  portion  of  the  urethra  anterior 
or  external  to  the  compressor  urethrae  is  the  habitat  of  bacteria 
in  varying  numbers  in  the  normal  state,  and  the  varieties  have 
been  investigated  by  Petit  and  Wassermann,  Pfeifier,  and  others. 
Anaerobic  bacteria  are  more  abundant  than  aerobic.  The  most 
constant  bacteria  are  Loffler's  bacillus,  the  streptobacillus  urethrse, 
the  colon  bacillus,  and  'the  staphylococcus  (albus  42  per  cent., 
aureus  20  per  cent.,  citreus  12  per  cent.).  The  prostatic  urethra 
is  aseptic.  The  female  urethra  also  contains  bacteria  in  the  natural 
state.  The  bacillus  coli  has  been  found  by  recent  observers  in 
from  12  to  66  per  cent,  of  cases,  and  the  staphylococcus  albus  and 
aureus  in  from  14  to  90  per  cent. 

In  the  great  majority  of  cases  urethritis  is  primarily  due  to 
the  gonococcus.  Urethritis  is  described  as  aseptic  when  bacteria 
are  completely  absent  from  the  discharge.  The  injection  of 
strong  irritating  solutions  into  the  urethra,  the  ingestion  of  certain 
urinary  irritants  such  as  large  quantities  of  asparagus,  and  alcoholic 
excess  in  some  individuals,  are  occasional  causes  of  urethritis  in 
those  who  have  not  previously  suffered  from  venereal  disease. 
Gout  and  rheumatism  are  doubtful  causes  of  urethritis.  Septic 
non-gonococcal  urethritis  is  more  common,  but  it  also  is  a  rare 
condition  where  there  has  never  been  gonorrhoeal  infection.  The 
infection  may  be  carried  by  instruments  such  as  a  catheter  or 
bougie,  or  the  bacteria  may  be  already  present  and  the  exciting 
factor  is  injury  from  instruments  or  an  irritating  urine  as  in 
diabetes  mellitus  ;  or  an  infection  with  bacteria  other  than  the 
gonococcus  may  result  from  connection  with  women  suffering  from 
leucorrhcea  or  during  menstruation.  Septic  urethritis  following 
upon  gonorrhoeal  urethritis  is  very  common.  After  a  varying 
period  the  virulence  of  the  gonococcus  subsides,  and  it  may  be 

595 


596  THE   URETHRA  [chap. 

replaced  by  a  mixed  infection  of  bacteria  already  present  in  the 
urethra  or  introduced  by  means  of  instruments. 

ACUTE   GONOCOCCAL  URETHRITIS  (GONORRHCEA) 

The  infection  in  gonorrhoea  almost  invariably  follows  con- 
nection ;  rarely  it  is  conveyed  indirectly  by  means  of  clothes, 
towels,  instruments,  etc.,  which  have  been  smeared  with  pus  con- 
taining the  gonococcus.  Certain  individuals  appear  to  be  par- 
ticularly susceptible  to  the  invasion  of  the  gonococcus,  and  others 
are  unusually  resistant.  Ill-health,  alcoholic  excess,  hypospadias, 
and  phimosis  have  a  predisposing  influence. 

Any  age  and  either  sex  may  be  attacked.  The  gonococcus  is  a 
diplococcus,  each  coccus  being  shaped  like  a  coffee-bean,  with 
the  concavity  facing  the  other.  It  occurs  in  groups  of  four  or 
multiples  of  four,  usually  numbering  twenty,  thirty,  or  forty. 
They  are  found  free  in  the  discharge  or  adhering  to  the  surface  of 
desquamated  epithelial  cells  or  lying  within  the  leucocytes.  In 
the  latter  position  they  lie  superficially,  and  may  be  so  numerous 
as  to  obscure  the  nucleus. 

The  gonococcus  is  cultivated  with  difficulty,  and  the  media 
most  favourable  for  its  growth  are  "  blood  agar "  and  "  serum 
agar."  In  culture  they  show  a  tendency  to  degeneration,  forming 
single  smaller  irregularly  staining  cocci. 

Except  in  artificial  conditions  such  as  cultures,  the  gonococcus 
does  not  flourish  outside  the  body,  but  it  may  remain  alive  for 
several  days  in  thick  pus.  It  stains  deeply  with  methylene  blue 
and  other  basic  aniline  dyes,  and  is  negative  to  Gram's  stain 
("  Gram  negative ").  The  gonococcus  produces  a  toxin  which, 
when  introduced  into  the  human  urethra,  causes  an  acute  purulent 
catarrh. 

After  introduction  into  the  meatus  the  infection  travels  back- 
wards on  the  surface  of  the  mucous  membrane  towards  the  bladder. 
The  whole  length  of  the  anterior  urethra  becomes  involved,  and 
it  spreads  to  the  posterior  urethra  in  from  80  to  90  per  cent,  of 
cases.  The  bladder  is  rarely  affected.  The  lacunae  of  the  urethra 
are  invaded,  and  perilacunar  leucocytic  infiltration  is  a  prominent 
feature.  In  the  prostatic  urethra  the  glands  of  the  prostate,  the 
sinus  pocularis,  and  sometimes  the  ejaculatory  glands,  are  invaded. 
In  these  recesses  the  diplococcus  may  remain  for  some  years  after 
the  acute  symptoms  have  passed.  In  the  male  the  gonococcus 
finds  its  habitat  in  the  urethra  and  frequently  invades  the  prostate, 
seminal  vesicles,  and  epididymis.  In  the  female  it  is  chiefly  found 
in  the  urethra,  vagina,  cervix  uteri  and  Fallopian  tubes,  and  the 
Bartholinian  glands. 


xLvii]  GONORRHCEA  597 

The  conjunctiva  is  readily  infected  with  the  gonococcus,  and 
the  mouth,  nose,  and  rectum  may  become  involved.  The  gono- 
coccus has  been  found  in  pure  or  mixed  culture  in  inflamma- 
tion of  the  bladder,  kidneys,  peritoneum,  endocardium,  blood, 
joints,  muscles,  subcutaneous   tissues,  and  rarely  the  lung. 

The  changes  that  occur  in  the  urethral  mucous  membrane  have 
been  studied  by  Finger.  The  gonococci  penetrate  between  the 
epithelial  cells,  which  become  loosened  and  are  cast  oH  (period 
of  incubation),  and  eventually  reach  the  subepithelial  connective 
tissue.  Here  there  are  signs  of  acute  inflammation  ;  the  leucocytes 
take  up  the  gonococci  and  pass  to  the  surface,  already  partly 
denuded  of  epithelium,  as  pus  cells,  and  the  purulent  stage  becomes 
established.  Neither  the  gonococci  nor  the  leucocytes  appear  to 
be  adversely  affected  by  this  phagocytic  action.  Penetration  of 
the  gonococci  to  the  deeper  layers  of  the  mucous  membrane,  with 
the  consequent  changes,  is  most  marked  around  the  lacunae  and 
glands  of  the  urethra.  As  the  process  subsides  the  cocci  are 
removed  from  the  deeper  layers  by  the  leucocytes,  but  they  remain 
adhering  to  the  epithelial  cells,  and  are  especially  persistent  in  the 
lacunae. 

In  chronic  urethritis  further  changes  occur  which  will  be 
described  later. 

Symptoms  and  clinical  course. — After  infection  there  is  a 
varying  period  during  which  the  gonococci  multiply  and  pene- 
trate the  epithelium  of  the  mucous  membrane.  During  this  time 
there  are  no  symptoms.  The  period  of  incubation  lasts  from 
three  to  five  days,  but  there  have  been  exceptional  cases  where 
it  lasted  twelve  to  fifteen  or  even  thirty  days. 

There  is  at  first  slight  irritation  or  itching  at  the  meatus  and 
adjacent  urethra,  and  some  burning  on  micturition.  A  little 
yellowish  discharge  appears,  and  the  meatal  lips  are  glued  in  the 
morning.  For  two  or  three  days  the  symptoms  increase.  The 
discharge  becomes  copious  and  purulent,  and  may  consist  of 
watery  pus  ;  but  more  frequently  it  has  a  creamy  consistence 
and  a  yellow  or  greenish-yellow  colour.  The  urine  now  scalds, 
and  micturition  may  cause  severe  burning,  cutting  pain.  The 
urine  is  milky  with  pus,  which,  on  standing,  quickly  settles  as  a 
heavy  layer  with  a  cloud  of  mucus  on  the  top.  On  microscopical 
examination  in  the  early  stage  the  discharge  is  foimd  to  consist 
largely  of  desquamated  epithelium  with  a  few  leucocytes ;  but 
when  the  discharge  has  fully  developed  it  consists  of  pus  cells, 
and  few  epithelial  cells  are  found.  In  the  late  stage  epithelial 
cells  again  become  prominent  and  are  embedded  in  mucus,  while 
the  leucocytes  are  few  in  number. 


598  THE   URETHRA  [chap. 

The  meatus  is  red,  swollen,  and  inflamed,  with  pouting  Hps, 
and  the  glans  and  foreskin,  if  there  is  phimosis,  are  bathed  in 
watery  pus.  The  urethra  is  tender  and  thickened  along  the  penis 
and  in  the  perineum.  The  foreskin  becomes  red  and  swollen, 
and  this  may  spread  to  the  skin  of  the  penis,  the  lymphatics  being 
marked  out  as  red  streaks. 

The  glands  of  the  upper  group  of  lymphatics  become  painful, 
tender,  and  swollen.  Erections  occur  at  night  and  cause  intense 
pain.  The  thickened,  inflamed  urethra,  from  its  loss  of  elasticity, 
causes  downward  curvature  of  the  penis  (chordee).  Following 
the  erections  the  discharge  is  frequently  blood-stained,  and  a 
considerable  amount  of  pure  blood  may  escape.  This  is  due  to 
tearing  of  the  softened,  inflamed  mucous  membrane.  The  constant 
discomfort  and  aching  in  the  urethra,  pain  and  scalding  on  mic- 
turition, and  sometimes  the  frequency  of  the  act  and  the  painful 
erections,  rob  the  patient  of  his  sleep. 

General  symptoms  are  almost  invariably  present.  The  patient 
is  pale  and  feels  ill  and  miserable,  the  appetite  is  poor,  and  there 
is  frequently  a  rise  of  one  or  two  points  in  the  temperature.  These 
symptoms  develop  during  the  first  week  or  ten  days  after  the 
discharge  has  appeared,  and  increase  or  remain  stationary  during 
the  next  fortnight,  when  they  begin  to  subside,  and  at  the  end 
of  about  six  weeks  only  a  slight  mucopurulent  discharge  without 
symptoms  remains,  and  this  quickly  disappears. 

This  is  the  course  followed  in  a  moderately  severe  case  without 
complications.  The  duration  may  be  shorter  than  that  described, 
or  it  may,  owing  to  complications  or  to  extension  of  the  inflamma- 
tion to  the  prostatic  urethra,  be  prolonged;  or  the  inflammation 
may  subside  and,  as  a  result  of  some  dietetic  indiscretion  or  other 
cause,  a  recrudescence  takes  place. 

The  most  frequent  departure  from  the  course  of  the  disease 
already  described  is  extension  of  the  inflammation  to  the  prostatic 
urethra.  This  occurs  in  the  second  or  third  week,  and  so  fre- 
quently that  it  is  sometimes  regarded  as  the  natural  course  in  all 
cases.  In  about  80  per  cent,  of  cases  some  degree  of  posterior 
urethritis  is  present,  but  only  in  a  smaller  number  of  cases  are  the 
symptoms  at  all  prominent.  Extension  to  the  posterior  urethra 
may  occur  without  apparent  cause,  or  it  may  follow  dietetic  indis- 
cretion, exercise,  exposure  to  cold,  or  any  condition  which  aggra- 
vates the  inflammation  of  the  anterior  portion  of  the  urethra. 

The  symptoms  produced  by  extension  of  the  inflammation  to 
the  posterior  prostatic  urethra  are  sudden  desire  to  pass  water 
and  constant  irritation.  There  is  pain,  sometimes  of  a  cramping 
nature,  at  the  end  of  micturition,  and  frequently  sonie  bright  blood 


xLvii]  GONORRHOEA:    DIAGNOSIS  599 

is  expressed  with  tlio  last  drops  of  uriiio.  A  licavy  aching  pain  is 
often  present,  but  wiien  tliis  Is  marked  it  is  usually  due  to  exten- 
sion to  the  prostate  gland  and  the  onset  of  prostatitis. 

The  occurrence  of  painful  erections  is  increased,  and  there  are 
frequent  seminal  emissions,  which  may  be  blood-stained. 

Diagnosis. — The  onset  of  symptoms  of  urethritis  a  few  days 
after  a  suspicious  connection  is,  in  the  majority  of  cases,  due 
to  gonococcal  invasion.  The  only  certain  test  is,  however,  the 
discovery  of  the  diplococcus  of  Neisser.  The  discharge  should 
be  examined  in  the  following  manner  :  A  very  small  drop  is 
placed  on  a  clear  glass  slide,  either  by  means  of  a  platinum  loop, 
which  has  previously  been  sterilized  by  heating  to  redness,  or  by 
applying  the  slide  directly  to  the  meatus  after  washing  the  glans 
penis.  A  second  slide  is  drawn  edgewise  along  this  so  as  to  leave 
a  very  thin  film  of  the  discharge.  The  slide  is  dried  over  a  spirit- 
lamp,  and  a  few  drops  of  methylene-blue  solution  are  poured 
over  it.  This  is  gently  heated  over  the  flame  for  a  few  minutes, 
and  then  the  slide  is  washed  in  running  water  and  again  dried. 
A  drop  of  cedar-wood  oil  is  placed  on  the  stained  film,  which  is 
examined  under  an  oil  immersion  lens  (yV  in.).  The  leucocytes 
are  stained  a  faint  blue  with  deep-blue  nuclei,  and  the  epithelial 
cells  and  their  nuclei  are  also  well  stained.  The  gonococci  are 
deeply  stained ;  they  are  arranged  in  groups  of  ten,  twenty,  or 
thirty,  and  lie  inside  the  protoplasm  of  the  leucocytes  or  adhere  to 
the  surface  of  the  epithelial  cells,  or  they  may  be  found  in  groups 
free  in  the  discharge.  The  diagnosis  depends  upon  the  character 
of  the  diplococci,  the  grouping,  and  the  intracellular  position.  As 
the  cocci  are  negative  to  Gram's  stain,  this  should  be  used  if 
there  is  any  doubt  as  to  the  bacteriological  diagnosis.  When 
the  number  of  groups  of  gonococci  is  large  and  there  are  numer- 
ous extracellular  groups,  the  infection  may  be  regarded  as  a 
severe  one. 

The  diagnosis  of  extension  to  the  posterior  urethra  is  made  by 
noting  the  onset  of  frequent  and  urgent  micturition  and  other 
symptoms  already  described.  A  valuable  method  of  demon- 
strating the  presence  or  absence  of  posterior  urethritis  is  to  wash 
out  the  anterior  urethra  with  a  cold  solution  of  boric  acid  or  mth 
sterile  water  by  means  of  an  irrigator  and  a  glass  urethral  nozzle. 
The  cold  solution  promotes  contraction  of  the  compressor  urethrae 
and  prevents  the  fluid  from  passing  into  the  prostatic  urethra, 
and  the  head  of  water  (2  or  3  ft.)  is  only  sufficient  to  irrigate  the 
anterior  canal  without  forcing  the  compressor.  After  the  irriga- 
tion the  patient  passes  water.  If  the  uime  is  turbid  the  pus 
must  have  come  from  the  posterior  urethra. 


600  THE   URETHRA  [chap. 

Sir  Henry  Thompson's  two-glass  test  (p.  610)  may  be  used, 
but  it  has  little  value  in  acute  gonorrhoea. 

The  filtered  urine  contains  no  albumin,  or  only  a  trace,  in 
anterior  urethritis,  while  a  considerable  quantity  of  albumin  is 
present  in  posterior  urethritis.  The  origin  of  this  albumin  has 
not  been  satisfactorily  explained. 

Staining  the  discharge  with  eosin  shows  the  presence  of  eosino- 
phile  leucocytes,  which  are  said  to  be  especially  abundant  in 
posterior  urethritis. 

Treatment.  Prophylaxis. — The  prophylaxis  of  venereal  dis- 
ease has  received  attention  in  recent  years,  and  the  subject  has 
appealed  especially  to  the  medical  services  of  navies  and  armies, 
where  the  results  of  widespread  measures  of  prophylaxis  can  be 
checked  in  large  numbers  of  cases. 

Such  measures  as  the  isolation  of  cases  of  venereal  disease, 
the  inspection  of  prostitutes,  and  the  education  of  youths  in  sexual 
matters  and  venereal  disease,  do  not  come  within  the  scope  of 
this  work. 

Certain  measures  have,  however,  been  successfully  adopted 
to  reduce  the  liability  to  contagion,  and  demand  mention  here. 
Apart  from  the  use  of  an  impervious  condom,  certain  antiseptics 
have  been  used  after  intercourse.  Thorough  washing  with  soap 
and  water  and  the  passage  of  urine  immediately  after  connection 
may  also  prevent  infection,  and  are  important  adjuncts  to  the 
following  antiseptic  prophylactic  treatment. 

An  instillation  of  a  few  drops  of  protargol  solution  (5  or  10  per 
cent.)  in  glycerine  solution  (1  in  10),  or  argyrol  (20  per  cent.),  or 
albargin  (5  per  cent.),  or  mercuric  oxycyanide  (yV  per  cent.),  is  made 
into  the  anterior  part  of  the  urethra  by  means  of  a  glass  dropper 
or  a  small  syringe,  as  soon  after  connection  as  possible. 

Abortive  treatment. — The  gonorrhoeal  infection  commences 
at  the  external  meatus  and  spreads  backwards,  and  it  is  at  first 
confined  to  the  superficial  layers  of  the  epithelium.  It  is  possible 
in  the  early  stage,  when  the  inflammation  is  still  limited  to  the 
first  inch  or  so  of  the  canal,  to  arrest  the  progress  of  the  disease. 
When  the  signs  are  only  a  slight  tingling  or  irritation,  a  little  red- 
dening of  the  meatus,  and  turbidity  and  slight  increase  of  the 
moisture  at  the  meatus,  abortive  treatment  is  likely  to  be  success- 
ful. When,  however,  a  purulent  discharge  is  fully  established, 
this  treatment  will  certainly  fail,  and  may  increase  the  severity 
of  the  inflammation. 

The  patient  passes  water,  and  the  urethra  is  compressed  about 
2|  in.  from  the  meatus.  By  means  of  an  irrigator  and  a  glass 
urethral  nozzle  (Fig.  187),  or  of  a  glass  syringe,  the  anterior  part 


XLVIl] 


GONORRHOEA:    TREATMENT 


601 


of  the  urethra  is  washed  with  boric  solution.  A  glass  pipette  with  a 
rubber  teat  is  now  taken,  and  ^  drachm  of  eucaine  solution  (2  per 
cent.)  with  adrenalin  instilled  into  the  urethra  and  allowed  to 
remain  for  five  minutes.  This  is  followed  by  an  instillation  of 
silver  nitrate  (2  per  cent.)  solution  made  in  similar  fashion,  keeping 
up  pressure  with  the  finger  and  thumb  to  prevent  the  solution 
from  penetrating  to  a  deeper  part  of  the  canal.  After  allowing 
this  to  remain  for  five  minutes  in  the  canal  it  is  washed  out  with 
boric  solution.  The  application  may  be  repeated  in  forty-eight 
hours,  and  sometimes  a  third  instillation  may  be  made  after  a 
similar  interval.  In  the  interval  between  these  instillations  and 
following  them  the  irrigation 
method  should  be  used. 

Another  method  of  abort- 
ing the  disease  is  that  of  irri- 
gation of  the  urethra.  This  is 
carried  out  with  a  glass  irri- 
gator and  a  glass  urethral 
nozzle.  Warm  permanganate 
of  potash  solution  is  employed  ; 
the  strength,  commencing  with 
1  in  5,000  on  the  first  day, 
rises  gradually  to  1  in  1,000 
at  the  end  of  a  week.     A  large 

quantity  of  fluid  is  used — at  least  2  quarts  at  each  sitting.  The 
glass  reservoir  is  raised  2  ft.  or  3  ft.  above  the  level  of  the  patient. 
After  passing  water  the  patient  lies  upon  a  couch,  and  the  surgeon 
grasps  the  penis  in  the  left  hand  and  separates  the  lips  of  the 
meatus  while  he  holds  the  urethral  nozzle  in  the  right  hand  and 
controls  the  flow  by  pressure  of  the  third  and  fourth  fingers  on 
the  rubber  tube  behind  it.  The  stream  of  fluid  is  directed  to  the 
meatus,  which  it  washes  thoroughly.  Then  the  anterior  part  of 
the  penile  urethra,  and  finally  the  whole  length  of  the  anterior 
urethra,  is  irrigated.  The  utmost  gentleness  is  observed,  and 
the  flow  of  fluid  should  not  be  allowed  to  distend  the  urethra. 
This  is  repeated  twice  a  day,  morning  and  evening,  for  ten  days. 
After  the  first  two  days  the  discharge,  if  the  treatment  is  going 
to  succeed,  diminishes  and  disappears,  but  the  washing  should  not 
be  omitted  until  the  tenth  day ;  after  that  it  is  gradually  stopped. 
This  method  is  frequently,  but  not  invariably,  successful  in  cases 
seen  in  the  very  earliest  stage.  It  may  be  used  alone  or  in  com- 
bination with  the  instillation  method. 

Treatment  when   the   inflamnnation    is    fully    established 
consists  in  (1)  diet  and  rest,  (2)  internal  remedies,  (3)  injections. 


Fig. 


187. — Ryall's  glass   urethral 
nozzle. 


602  THE   URETHRA  [chap. 

The  treatment  should  commence  with  a  smart  saline  purge, 
and  the  patient  is  placed  upon  a  light  diet.  Excess  of  meat,  all 
highly  spiced  foods,  curries,  strawberries,  tomatoes,  asparagus, 
and  rhubarb  should  be  avoided.  Wines,  beer,  spirits — indeed, 
alcohol  in  any  form — is  forbidden.  If  possible,  the  patient  should 
be  confined  to  bed  for  a  week  or  ten  days  during  the  most  acute 
stage  of  the  disease,  or,  if  this  is  impracticable,  he  should  rest  as 
much  as  possible  on  a  couch.  Exercise  of  any  kind  should  be 
forbidden  ;  horse-riding  and  bicycling  are  especially  harmful.  A 
suspensory  bandage  should  be  worn,  and  the  penis  inserted  in  a 
gonorrhoea  bag  containing  wood-wool,  which  absorbs  the  discharge 
and  is  burnt  after  use  ;  or  a  square  of  aseptic  lint,  with  a  central 
aperture  through  which  the  penis  is  drawn,  may  be  attached  with 
safety-pins  to  the  suspensory  bandage  and  folded  around  the 
penis,  being  secured  with  a  safety-pin  or  a  light  elastic  band. 
The  foreskin  should  not  be  plugged  with  cotton-wool,  as  this 
prevents  the  escape  of  the  discharge.  Sexual  excitement  and  cold 
must  be  avoided.  The  patient  should  be  directed  to  drink  large 
quantities  of  fluid :  this  has  the  effect  of  diluting  the  urine  and 
rendering  it  less  irritating,  and  is  an  important  part  of  the  treat- 
ment- Barley-water,  parsley  tea,  hot  water,  Salutaris  water,  and 
any  of  the  alkaline  mineral  waters  may  be  taken.  Contrexeville 
water  should  be  prescribed,  at  least  a  bottle  being  consumed 
each  day. 

Urotropine  and  other  urinary  antiseptics  are  useless,  and  may 
increase  the  irritation  in  a  sensitive  mucous  membrane.  Certain 
balsams  have  long  been  used  as  internal  remedies — namely,  copaiva, 
cubebs,  and  sandalwood  oil.  Of  these,  sandalwood  oil  is  much 
the  most  efficacious  and  is  least  likely  to  cause  gastric  disturb- 
ance, rashes,  and  renal  aching.  Pure  sandalwood  oil  should  be 
used,  30  to  40  minims  in  twenty-four  hours,  and  may  be  prescribed 
in  the  form  of  capsules  or  in  a  mixture  containing  bicarbonate  of 
potash  and  spirits  of  nitrous  ether.  Indigestion,  renal  aching, 
and  the  appearance  of  albumin  and  tube  casts  in  the  urine  some- 
times follow  the  administration  of  sandalwood  oil  and  call  for 
the  omission  of  the  drug  or  reduction  of  the  dose.  In  such 
cases  preparations  such  as  santyl  (sandalwood  oil  with  salicylic 
acid,  10  or  15  minims  in  capsule  thrice  daily),  gonosan  (sandal- 
wood oil  with  kava  resin),  santalol  or  arheol  (capsules  5  minims 
thrice  daily),  or  santalol  methyl-salicyl  capsules  (santalol  4 
minims,  methyl  salicylate  1  minim)  may  be  given  with  good 
effect. 

Mistura  santali  composita  (Nisbet's  Specific),  J-1  drachm  in 
water  or  milk  thrice  daily,  liquor  copaibae  cum  buchu  et  cubeba, 


xLvii]  GONORRHOEA:    TREATMENT  603 

1-2  drachms  in  a  large  quantity  of  water,  or  liquor  santali  com- 
positus,  in  similar  doses,  are  also  useful.^ 

Injections  should  be  given  from  the  earliest  onset  of  the  dis- 
charge. They  should  be  avoided,  however,  when  the  urethritis 
is  very  severe  with  marked  oedema  of  the  penis  and  blood  in  the 
discharge,  and  should  be  omitted  when  such  complications  as 
posterior  urethritis  or  epididymitis  supervene. 

The  method  of  injection  is  either  by  irrigator  or  by  hand- 
syringe.  For  lavage  of  the  urethra  by  means  of  the  irrigator  the 
technique  is  similar  to  that  already  described  under  abortive  treat- 
ment. The  best  solution  is  weak  permanganate  of  potash  (1  in 
5,000),  and,  although  the  bactericidal  action  of  the  drug  is  very 
low  and  the  dilution  extreme,  it  frequently  exerts  a  very  remark- 
able effect  on  the  gonococcal  infection.  The  strength  may  be  care- 
fully raised  to  1  in  1,000.  Nitrate  of  silver  in  very  weak  solution 
(1  in  10,000  to  1  in  8,000)  is  sometimes  useful.  The  lavage  should 
be  carried  out  twice  daily.  Occasionally  an  intelligent  patient 
may  be  trusted  to  carry  out  the  irrigation  himself  without  balloon- 
ing the  urethra  or  using  too  strong  solutions,  but  this  is  seldom  safe 
and  as  a  rule  it  can  only  satisfactorily  be  done  by  the  medical 
attendant. 

For  hand  injections  a  syringe  should  be  chosen  with  glass 
barrel,  vulcanite  mountings,  and  a  rubber  piston,  and  it  should 
have  a  blunt  conical  nose  and  a  capacity  of  3  or  4  drachms. 

The  syringe  and  the  penis  are  washed  with  carbolic  lotion, 
the  injection  fluid  diluted  to  the  proper  strength  in  a  glass  and 
injected  slowly  into  the  urethra  after  the  bladder  has  been  emptied. 
When  the  anterior  urethra  is  moderately  distended  with  fluid 
(about  2  or  3  drachms)  the  syringe  is  removed  and  the  fluid  retained 
in  the  urethra  for  a  stated  period  (three  minutes)  by  grasping 
the  meatus  with  finger  and  thumb.  This  is  done  several  times, 
and  the  seance  is  repeated  at  regular  intervals  three  or  four  times 
during  the  day.  The  following  solutions  are  useful,  viz. :  potassium 
permanganate,  1  in  1,000  to  1  in  SCO  ;  protargol,  |-1  per  cent.  ;  or 
argyrol,  3-10  per  cent. 

In  the  later  stage,  when  the  discharge  is  subsiding,  mineral  or 
vegetable  astringents  should  be  used,  such  as  zinc  sulphocarbolate, 
2-4  gr.  to  the  ounce  ;  zinc  sulphate,  1-4  gr.  to  the  ounce ;  zinc 
permanganate,  ^|  gr.  to  the  ounce ;  alum,  1-2  gr.  to  the  ounce ; 
tannic  acid,  1-2  gr.  to  the  ounce ;  tincture  catechu,  15-20  minims 
to  the  ounce  ;  or  extract,  hydrastis  fi.,  30-60  minims  to  the  ounce. 
The  mineral  and  vegetable  astringents  may  be  combined. 

When  a  slight  discharge  continues  for  some  weeks,  in  spite  of 
1  Martindale,  Extra  Pharmacopoeia,  14th  ed.,  p.  501. 


604  THE   URETHRA  [chap. 

injections  and  other  treatment,  the  anterior  urethra  should  be 
irrigated,  and  the  urine  then  passed  and  examined.  If  the  urine  is 
cloudy  and  contains  shreds,  posterior  urethritis  is  present.  In  this 
case  an  instillation  of  silver  nitrate  (1  per  cent.)  by  means  of  a 
Guyon's  syringe  usually  suffices  to  clear  it  up. 

When  is  an  acute  attack  of  gonorrhoea  cured  ? — When  the 
discharge  has  entirely  ceased  the  injections  or  irrigations  should 
be  continued  for  a  week,  and  then  all  treatment  omitted.  The 
urine  is  now  examined  for  gonococci,  the  first  urine  passed  in  the 
morning  being  tested.  The  prostate  and  seminal  vesicles  should 
be  massaged  and  the  secretion  examined,  and  this  should  be  free 
from  gonococci.  The  examination  should  be  repeated  in  a  week 
after  the  patient  has  resumed  his  ordinary  habits  and  has  indulged 
in  alcohol,  and  if  the  two  examinations  are  negative  the  gonor- 
rhoea may  be  regarded  as  cured.  When  marriage  is  contemplated 
it  is  advisable  to  make  a  more  exhaustive  examination.  The 
prostate  and  seminal  vesicles  are  massaged,  and  the  secretion 
examined  for  gonococci.  The  anterior  urethra  is  dilated  with  large 
metal  sounds  or  Kollmann's  dilators,  and  any  discharge  that  can  be 
expressed  is  examined.  Finally,  a  few  drops  of  silver  nitrate  solution 
(2  per  cent.)  are  injected  into  the  posterior  and  anterior  urethra, 
and  the  resulting  discharge  carefully  examined.  This  examination 
may  be  repeated  after  an  interval.  An  injection  of  gonococcus 
vaccine  is  sometimes  given,  and  any  resulting  discharge  examined. 

The  presence  of  small  numbers  of  non-bacterial  shreds  in  clear 
urine  does  not  necessitate  treatment.  They  may  persist  for  many 
months  or  even  years,  and  are  harmless. 

Complications.— The  following  complications  may  arise  during 
the  course  of  an  attack  of  gonorrhoea,  viz. :  balanitis  ;  lacunar 
abscess  ;  periurethral  abscess  ;  inflammation  of  Cowper's  glands  ; 
suppurating  bubo  ;  spermato-cystitis  :  prostatitis  ;  cystitis  ;  pyel- 
itis and  pyelonephritis  ;  epididymitis  ;  salpingitis  ;  peritonitis  ; 
gonorrhoea  of  the  rectum  ;  gonorrhoeal  rheumatism  (gonorrhceal 
arthritis,  gonorrhceal  teno-synovitis,  gonorrhoeal  bursitis) ;  endo- 
carditis ;    gonorrhoeal  myositis. 

Only  a  few  of  these  need  be  considered  here,  most  of  the 
conditions  being  described  with  the  diseases  of  the  organs  which 
they  affect. 

Balanitis. — This  results  from  accumulation  of  discharge 
beneath  a  long  foreskin,  but  is  not  directly  caused  by  the  gono- 
coccus. The  foreskin  is  red  and  oedematous,  and  there  may  be 
spreading  cellulitis  of  the  skin  of  the  penis.  The  preputial  sac 
should  be  thoroughly  and  frequently  irrigated  with  solution  of 
permanganate  of  potash,  1  in  5,000,  or  nitrate  of  silver,  1  in  5,000. 


xLvii]        GONORRHCEA:    COMPLICATIONS  605 

When  the  inflammation  is  intense  and  is  spreading,  the  foreskin 
siiould  be  sUt  up  and  circumcision  performed,  and  the  penis  enclosed 
in  hot  antiseptic  fomentations  and  immersed  for  half  an  hour  at 
a  time  in  a  bath  of  hot  permanganate  solution. 

Lacunar  abscess. — This  usually  forms  a  small,  split-pea- 
sized  nodule  in  the  urethral  mucous  membrane,  and  occurs  more 
frequently  in  chronic  urethritis  than  during  the  course  of  an  acute 
attack  of  gonorrhoea.  In  chronic  cases  it  is  readily  demonstrated 
by  passing  a  bougie  along  the  urethra.  No  special  treatment 
is  required  in  acute  cases,  but  in  chronic  urethritis  the  lacunar 
abscess  should  be  incised  from  within  the  urethra  by  means  of 
a  Wagner's  urethral  knife,  or  a  fine  electric  cautery  passed  through 
a  urethroscopic  tube. 

A  larger  abscess  originating  in  a  lacuna  may  develop  in  acute 
gonorrhoea.  This  is  described  under  Periurethral  Abscess  (p.  647). 
Bubo  and  suppurating  bubo. — Lymphadenitis  of  the  in- 
guinal glands  is  usually  present,  and  the  glands  are  enlarged, 
tender,  and  discrete.  In  some  cases  they  become  matted  together, 
and  occasionally  suppuration  occurs.  If  the  lymphadenitis  is 
severe  the  patient  should  be  confined  to  bed  and  fomentations 
applied.  Should  suppuration  take  place  a  free  vertical  incision 
is  made,  the  cavity  swabbed  with  iodine  solution,  and  packed. 
Healing  is  sometimes  delayed,  especially  when  the  patient  is 
unable  to  rest. 

Gonorrhoea!  rheumatism.  1.  Gonorrhceal  arthritis.  —  The 
most  frequent  form  of  metastasis  of  the  gonococcus  is  seen  in 
gonorrhceal  arthritis. 

Gonococci  have  been  demonstrated  in  the  contents  of  the 
joint  in  these  cases.  This  occurs  in  women  as  well  as  in  men, 
although  it  is  less  common  in  the  female.  It  occurs  in  2  per  cent, 
of  cases  (Besnier  and  Julien). 

The  localization  to  one  joint  may  be  influenced  by  slight  injury 
or  strain  thrown  on  the  joint. 

Gonorrhceal  rheumatism  appears  in  the  third  week  of  the 
urethritis.  The  joint  is  painful,  tender,  swollen,  and  the  tempera- 
ture raised.  One  joint  is  usually  affected,  but  exceptionally 
several  joints  may  be  invaded.  Finger  found  the  following  fre- 
quency of  the  various  joints  in  376  cases  :  knee  136,  tibio-tarsal 
joint  59,  wrist  43,  finger-joints  35,  elbow  25,  shoulder- joint  24, 
hip-joint  18,  mandibular  joint  14,  metatarsal  joints  7,  other  joints 
15.  The  changes  may  take  several  forms  :  (1)  hydrops,  (2)  sero- 
fibrinous inflammation,  (3)  suppuration,  (4)  fulminating  arthritis. 
There  is  a  tendency  to  recurrence  in  the  hydrops  form,  and  the  con- 
dition may  become  chronic.     In  the  sero-fibrinous  and  suppurative 


606  THE   URETHRA  [chap. 

t}^es  adhesions  tend  to  form  and  ankylosis  may  result.  In 
the  fulminating  form  the  acute  inflammation  spreads  to  all  the 
tissues  around  the  joint.  Extreme  distortion  and  ankylosis  of 
the  joint  follow. 

Prognosis  is  good  as  regards  life,  and  in  the  slight  degrees  com- 
plete recovery  may  be  expected.  In  very  chronic  and  in  severe 
arthritis  a  stiff  joint  is  frequently  the  result. 

Treatment  in  the  acute  stage  consists  in  immobilizing  the  joint 
and  applying  heat  and  soothing  lotions.  After  the  acute  stage 
is  over,  as  soon  as  possible,  gentle  manipulation  of  the  joint  and 
massage  of  the  periarticular  tissues,  tendons,  and  muscles  should 
be  systematically  undertaken,  and  elastic  pressure  applied  by 
means  of  crepe  bandages  and  cotton-wooL  Bier's  congestion 
method  has  given  good  results.  Pressure  is  applied  by  an  elastic 
bandage  on  the  proximal  side  of  the  joint,  and  causes  venous 
congestion  without  obstructing  the  arterial  supply.  This  should 
be  maintained  for  several  hours  daily,  depending  upon  the  acute- 
ness  of  the  arthritis  and  the  result  of  the  treatment. 

Radiant  heat  is  very  efficacious  in  many  cases.  The  joint  is 
placed  in  a  chamber  with  incandescent  electric  lamps,  and  the 
heat  raised  to  200°  F.  or  over  for  half  an  hour.  This  treatment 
is  applied  once  or  twice  a  week. 

Salicylates  may  be  administered,  but  have  no  marked  effect. 
Iodide  of  potash  is  preferable. 

The  urethral  discharge  should  be  carefully  treated.  Gono- 
coccal vaccine  is  of  considerable  value  in  these  cases,  and  should 
always  be  tried. 

2.  Gonorrhceal  tenosynovitis. — This  may  occur  with  gonor- 
rhoeal  arthritis,  or  it  may  develop  apart  from.it,  especially  in  the 
tendon  sheaths  of  the  hand  and  foot,  the  extensors  of  the  fingers 
and  toes  being  principally  afiected.  There  is  slight  fever  followed 
by  tenderness,  swelling,  and  stiffness  of  the  affected  parts,  and 
the  skin  is  red  and  oedematous. 

Gonococci  have  been  found  in  the  turbid  exudate. 

The  condition  subsides  in  a  fortnight  or  three  weeks,  usually 
with  full  restoration  of  function.  Limitation  of  movement  may, 
however,  occur,  especially  where  a  neighbouring  joint  is  affected. 

The  treatment  is  similar  to  that  used  in  gonorrhceal  arthritis. 

NON-GONOCOCCAL  SEPTIC  URETHRITIS 

Septic  urethritis  has  long  been  recognized,  but  the  condition 
has  been  placed  on  a  sound  basis  by  the  work  of  Guiard,  Nogues, 
Vamrod,  Hume,  and  others.  All  cases  where  there  has  been  a 
previous  infection  with  the  gonococcus  must  be  excluded  from 


xLvii]        NON-GONOCOCGAL   URETHRITIS  007 

this    category,  and   Hume    excludes   also    cases   that    have    been 
injected,  irrigated,  or  had  instruments  passed. 

There  are  two  general  types  of  non-specific  urethritis  : 

1.  Sexual  or  infective  urethritis.     Acute  urethritis  following 

coitus  after  a  regular  incubation  period. 

2.  Auto-infective    or    autogenous    urethritis.     Chronic    ure- 

thritis which  has  been  chronic  from  the  first. 

1.  Acute  non-gonococcal  urethritis. — This  is  a  rare  condition, 
which  occurred  in  only  11  out  of  493  of  Hume's  cases. 

The  incubation  period  is  similar  to  that  of  gonorrhoea,  lasting 
from  five  to  nine  days,  but  it  is  frequently  less.  The  lips  of  the 
urethra  are  puffy  and  red,  and  there  is  a  moderately  profuse  watery 
yellow  discharge.  The  urine  first  passed  is  hazy  and  contains 
shreds,  while  the  second  glass  contains  clear  urine.  Urethro- 
scopical  examination  shows  no  infiltration  of  the  mucous  mem- 
brane in  a  recent  attack. 

According  to  Hume,  there  are  numerous  bacteria  which  are 
usually  in  pure  culture,  or  there  is  a  markedly  predominating 
bacterium  in  a  mixed  infection.  The  most  frequent  organism  is 
the  staphylococcus  albus.  The  colon  bacillus  is  occasionally 
present,  but  more  often  an  unnamed  lanceolate  diplobacillus. 
The  streptococcus  has  also  been  described. 

The  prognosis  is  good,  complete  recovery  following  appropriate 
treatment. 

2.  Chronic  auto-infective  urethritis. — The  urethritis  is  chronic 
from  the  commencement,  and  is  more  common  than  the  sexual 
variety  (30  in  493  cases). 

The  incubation  period  is  ill  defined,  and  the  discharge  may  be 
discovered  some  time  after  comiection,  or  if  the  patient  is  observant 
it  may  be  found  when  no  connection  has  taken  place.  It  is  shght 
and  greyish  or  white.  The  first  urine  is  clear,  with  floating  shreds, 
and  the  second  normal.  Examination  with  the  urethroscope  shows 
old-standing  infiltration  of  the  urethral  mucous  membrane.  In- 
duration of  the  prostate  and  slight  chronic  seminal  vesiculitis  may 
be  present. 

Hume  suggests  that  the  condition  may  be  predisposed  to  by 
the  presence  of  a  long  foreskin,  which  encourages  the  growth  of 
bacteria,  and  that  it  may  commence  in  early  youth  and  only  be 
discovered  when  it  is  aggravated  by  irritating  drinks,  acid  urine, 
connection,  or  other  causes  which  encourage  inspection  of  the 
urethra.  Acute  exacerbations  frequently  occur,  and  the  presence 
of  this  condition  may  adversely  influence  the  course  of  an  inter- 
current attack  of  gonorrhoea. 

The  prognosis  is  not  so  good  as  in  the  sexual  variety.     The 


608  THE   URETHRA  [chap. 

condition  may  persist  for  months  or  even  years.  Neurasthenia 
may  be  present  in  long-standing  cases. 

Treatment. — Daily  irrigation  with  permanganate  of  potash 
in  increasing  strength,  and  an  injection  of  nitrate  of  silver  twice 
a  week,  ^|  per  cent.,  or  injections  of  protargol,  |  per  cent.,  should 
be  used.  Sandalwood  oil  should  be  administered  internally.  An 
injection  of  sulphate  of  zinc,  j-J  per  cent.,  should  be  used  as  the 
discharge  is  subsiding. 

In  chronic  auto-infective  urethritis  circumcision  should  first  be 
performed,  and  the  urethra  treated  with  irrigations  of  perman- 
ganate of  potash  or  of  nitrate  of  silver,  1  in  10,000  up  to  1  in  5,000, 
and  large  metal  instruments  passed  or  Kollmann's  flushing  dilators 
used.  Applications  of  stronger  solutions  of  nitrate  of  silver,  1  or 
2  per  cent.,  may  be  made  through  the  urethroscope  tube.  Hume 
recommends  the  use  of  ichthyol  or  balsam  of  Peru,  in  full  strength, 
or  with  equal  parts  of  lanolin,  in  sluggish  cases. 

LITERATURE 

Alsberg,  Arch.  f.   Gyn.,  1910,  xc.  255. 

Eitner,    Wien.  med.   Woch.,  1909,  lix.  2411,  2474. 

Finger,  Die  Syphilis  und  die  venerischen  Kranhheiten,  1896  ;    Wiener  Klinih,  1900. 

Hume,   Journ.  of  Amer.  Med.  Assoc,  1910,  liv.  1675. 

Leedham-Green,   Treatment  of  Gonorrhoea.     1908. 

Petit  et  Wassertnann,  Ann.  d.  Mai.  d.  Org.   Gen.-  Urin.,  1891,  p.  378. 

Pfeiffer,  Arch.  f.  Derm.  u.  Syph.,  Bd.  Ixix.,  Heft  3,  S,  379. 

Porosz,  Monats.  f.   Urol.,  1904,  Bd.  ix.,  Heft  11. 

Vamrod,  Ann.  d.  Mai.  d.  Org.   Gen.-  Urin.,  1905,  No.  6. 

Wossidlo,  Die  Gonorrhoe  des  Mannes.     1909. 

CHRONIC  URETHRITIS— GLEET 

Chronic  urethritis  follows  upon  acute  gonorrhoea,  and  may 
be  due  to  the  gonococcus,  or  this  may  have  disappeared  and 
given  place  to  other  bacteria.  A  form  of  non-gonorrhoeal  chronic 
urethritis  has  already  been  described. 

Etioloi^y. — Want  of  proper  treatment,  treatment  with  too 
strong  applications,  the  early  return  to  alcohol  or  sexual  inter- 
course, repeated  fresh  infection  with  gonococcus,  neglect  by  the 
patient  to  continue  treatment  until  a  cure  is  effected,  are  recog- 
nized causes  of  chronic  urethral  infection.  Debility,  the  gouty 
or  tuberculous  diathesis,  alcoholism,  and  apparently  in  some  cases 
idiosyncrasy,  act  as  predisposing  factors,  while  local  conditions, 
such  as  a  narrow  meatus,  phimosis,  stricture,  and  hypospadias, 
act  mechanically  in  preventing  free  egress  of  the  discharge. 

Pathology. — In  the  anterior  urethra  there  are  changes  in  the 
glands  and  lacunae.  The  lacuna  magna,  the  normally  placed 
lacunae  on  the  roof  of  the  urethra,  or  large  abnormal  lacunae,  con- 


XLvii]  GLEET  609 

tain  pus  and  are  surrounded  by  round-cell  infiltration  ;  occasion- 
ally the  outlet  of  a  lacuna  or  of  several  lacunae  becomes  blocked, 
and  the  pus  and  secretion  distend  it  to  form  a  small  cyst  or 
abscess.  There  are  patches  of  infiltration  with  round  cells  of  vary- 
ing extent  surrounding  the  urethral  glands  and  with  a  slightly 
raised  surface.  Later  the  patch  becomes  organized  to  form  scar 
tissue.  The  surface  of  epithelium  is  changed  in  character,  the 
transitional  epithelium  being  transformed  into  a  thick  layer  of 
squamous  epithelium.  These  patches  of  infiltration  are  the  early 
stage  in  the  formation  of  a  fibrous  stricture. 

Ulceration  of  the  mucous  membrane  is  very  rarely,  if  ever, 
seen.  Cowper's  ducts  are  rarely  the  cause  of  chronic  urethritis, 
but  they  may  occasionally  be  found  inflamed  with  purulent  con- 
tents. In  the  posterior  urethra  the  sinus  pocularis  is  frequently 
the  seat  of  chronic  inflammation  and  a  continued  source  of  in- 
fection of  the  urethra.  The  ducts  of  the  prostatic  glands  opening 
into  the  prostatic  sinuses  and  the  ejaculatory  ducts  opening  on 
the  verumontanum  are  channels  by  which  infection  is  constantly 
poured  into  the  urethra  in  chronic  prostatitis  and  seminal  vesi- 
culitis respectively. 

Symptoms. — The  symptoms  of  chronic  urethritis  are  dis- 
charge, changes  in  the  urine,  changes  in  micturition,  and  sexual 
irritation. 

The  discharge  varies  greatly  in  amount.  There  may  be  a  very 
slight  discharge  continuously  present,  gluing  the  lips  of  the  meatus 
and  staining  the  linen ;  or  there  may  be  a  single  drop  in  the  morn- 
ing and  none  during  the  day ;  or  no  discharge  appears  at  the 
meatus  unless  the  urethra  is  stripped  with  the  finger.  The  dis- 
charge is  yellow,  yellowish  white,  white,  or  greyish  white. 

Changes  in  the  urine  consist  in  cloudiness,  due  to  mucus  and 
a  little  pus  and  the  presence  of  urethral  threads. 

Urethral  threads  consist  of  mucus  in  which  are  embedded 
epithelial  cells  and  pus  cells  in  varying  proportions  and  bacteria. 
The  epithelial  cells  are  more  prominent  in  the  slight  forms  of 
urethritis,  while  in  the  more  acute  and  severe  forms  the  shreds  are 
purulent.  The  threads  are  formed  from  the  film  of  discharge  which 
adheres  to  an  inflamed  area.  When  micturition  takes  place  the 
film  is  detached,  rolled  up,  and  swept  away  in  the  urine.  Number- 
less long,  irregular  shreds  of  varying  size  are  found  where  the 
urethritis  is  subacute  and  extensive.  They  are  usually  suspended 
in  a  cloudy  urine.  Smaller  regular  threads  of  equal  size  are 
found  in  clear  urine  in  chronic  cases.  Very  small  fine  threads, 
frequently  comma-shaped,  are  plugs  from  the  gland  ducts  and 
emanate  from  the  prostate.  In  some  slight  cases  of  catarrhal 
2  N 


610  THE   URETHRA  [cuap. 

urethritis  innumerable  flat  flakes  of  epithelium  like  bees'  wings 
are  seen  floating  in  clear  urine,  and  quickly  fall  to  the  bottom 
of.  the  glass.  A  single  long  coiled  thread  is  found  in  some  cases 
where  a  single  localized  area  of  inflammation  is  present.  In 
slight  catarrhal  urethritis  at  the  close  of  a  urethral  infection  the 
threads  become  transparent  and  filmy. 

Where  the  posterior  urethra  is  afiected  there  are  urgency  and 
increased  frequency  of  micturition.  This  may  be  so  slight  as  to 
be  hardly  noticeable,  but  it  may  also  be  severe,  and  there  may 
be  an  involuntary  escape  of  urine  (active  incontinence)  from  un- 
controllable spasm  when  no  opportunity  is  presented  for  passing 
water.  The  symptoms  may  amount  only  to  a  slight  burning 
during  micturition.  Seminal  emissions  may  be  frequent,  and 
there  may  be  premature  ejaculation. 

The  general  health  of  the  patient  is  frequently  depressed  from 
emissions,  constant  irritation  in  the  urethra,  and  reflected  pain 
from  chronic  prostatitis.     Sexual  neurasthenia  is  apt  to  develop. 

Diagfnosis. — The  diagnosis  of  chronic  urethritis  consists  in 
ascertaining  the  position  of  the  lesion,  in  recognizing  its  nature, 
and  in  forming  a  conclusion  as  to  when  the  condition  is  cured. 

1.  History. — If  there  has  been  epididymitis,  or  the  patient 
gives  a  history  of  prostatitis  and  there  are  symptoms  of  sexual 
irritation  and  of  frequency  and  urgency  of  micturition,  the  seat 
of  inflammation  will  be  found  in  the  prostatic  urethra,  whereas, 
if  this  history  and  these  symptoms  are  absent,  the  lesion  may 
be  in  the  anterior  urethra,  and  this  is  more  probable  if  there  is 
some  spot  of  tenderness  in  this  part  of  the  canal  on  palpation  or 
on  passing  urine. 

2.  Examination  of  the  urine. — A  large  number  of  clinical 
tests  have  been  applied  to  this  part  of  the  examination. 

i.  Thomfson's  two-glass  test. — The  patient  passes  urine  into 
two  glasses.  If  the  first  urine  is  cloudy  and  the  second  clear, 
the  anterior  urethra  is  affected  alone  and  the  prostatic  urethra 
and  bladder  are  free.  If  both  urines  are  cloudy  there  is  said  to 
be  inflammation  of  both  anterior  and  posterior  urethra.  Certain 
fallacies  reduce  the  value  of  this  test.  Both  urines  are  cloudy 
not  only  where  there  is  anterior  and  posterior  urethritis,  but  also 
where  there  is  a  very  copious  discharge  from  the  anterior  urethra, 
and  where  there  is  severe  posterior  urethritis  without  anterior 
urethritis  (an  uncommon  condition).  The  turbidity  of  the  second 
urine  is  usually  due  to  regurgitation  of  discharge  from  the  posterior 
urethra  into  the  bladder,  and  it  has  been  pointed  out  that  this 
occurs  especially  at  night,  when  the  urine  is  long  retained  in  the 
bladder  and  the  secretion  has  time  to  collect.      As  a  result,  in 


xLvii]  GLEET:   DIAGNOSIS  611 

mild  cases  of  posterior  urethritis  the  two-glass  test  will  show  two 
turbid  urines  in  the  morning  and  a  turbid  first  and  clear  second 
urine  during  the  day. 

ii.  Jadassohn  s  three-glass  test. — The  urine  is  passed  into  three 
glasses.  The  first  urine  contains  the  sweeping  of  the  whole  urethra, 
the  second  any  discharge  that  may  have  regurgitated  into  the 
bladder,  and  the  third  the  discharge  which  may  be  squeezed  from 
the  prostate  gland  by  the  final  contraction  of  the  prostatic  and 
urethral  muscles. 

iii.  The  most  satisfactory  method  is  to  irrigate  the  anterior 
urethra  with  cold  boric  solution  until  all  pus  or  threads  are  washed 
out.  This  is  best  done  by  an  irrigator  and  glass  urethral  nozzle, 
the  head  of  water  not  exceeding  2  ft.  The  cold  lotion  produces 
contraction  of  the  compressor  urethrse,  and  prevents  the  wash 
from  penetrating  into  the  prostatic  urethra.  The  patient  then 
passes  urine  into  two  glasses.  The  first  glass  receives  the  washing 
of  the  anterior  urethra,  the  second  the  content  of  the  prostatic 
urethra  and  bladder  washed  out  by  the  urine,  and  the  third  the 
discharge  expressed  from  the  prostatic  gland  by  the  terminal 
urethral  and  prostatic  contraction  and  contained  in  the  last  por- 
tion of  urine. 

In  order  to  demonstrate  more  clearly  the  flakes  which  come 
from  the  anterior  or  washed  portion  of  the  urethra,  the  fluid  may 
be  coloured  with  methylene  blue,  or  a  solution  of  potassium  per- 
mianganate  may  be  used,  so  that  the  shreds  are  stained. 

iv.  Wolharst's  method  is  a  further  modification  of  these  tests, 
and  is  more  accurate  in  differentiating  between  pus  from  the 
prostatic  urethra  and  that  from  the  bladder.  It  is  an  easily  used 
and  very  useful  method  of  localizing  the  seat  of  inflammation. 
{a)  The  anterior  urethra  is  irrigated  until  the  washings  are 
clear.  (6)  A  soft  sterile  catheter,  lubricated  with  glycerine,  is 
passed  into  the  bladder,  the  contents  are  drawn  off,  the  bladder  is 
carefully  washed,  and  8  oz.  of  fluid  are  left  in  it.  (c)  The  patient 
passes  2  oz.  of  fluid,  {d)  The  prostate  is  massaged,  and  the  patient 
passes  the  remainder  of  the  fluid. 

Glass  1  represents  the  anterior  urethra,  Glass  2  the  bladder, 
Glass  3  the  prostatic  urethra,  and  Glass  4  the  contents  of  the 
prostatic  gland. 

3.  Palpation  and  rectal  examination. — Palpation  of  the 
penile  and  bulbous  portions  of  the  urethra  may  show  some  tender 
spot,  and  on  passing  a  bougie  along  the  urethra  the  patient  com- 
plains of  tenderness  at  this  point.  Rectal  examination  may  show 
induration  of  the  prostate  and  thickening  of  the  seminal  vesicles, 
and  there  may  be  tenderness  in  the  line  of  the  prostatic  urethra. 


612  THE   URETHRA  [chap. 

4.  Examination  of  the  discharge. — If  the  discharge  is  suffi- 
cient in  quantity  a  smear  is  taken  on  a  glass  slide  after  washing 
the  glans  and.  meatus.  It  may  be  necessary  to  strip  the  urethra 
by  running  the  forefinger  along  the  perineum  and  under  surface 
of  the  penis  from  behind  forwards  in  order  to  obtain  a  bead  of 
discharge.  A  second  glass  slide  is  drawn  firmly  along  the  j&rst 
at  an  angle  of  45°  so  as  to  spread  the  film  thinly  over  the  surface. 
This  is  then  gently  heated  to  dryness  and  passed  three  times  over 
the  flame  of  a  spirit-lamp  to  fix  the  film.  Should  no  discharge 
be  obtainable  in  this  way  the  urine  is  centrif ugalized,  and '  the 
deposit  containing  the  threads  is  sucked  into  a  pipette,  placed 
on  a  clean  slide,  and  prepared  as  before. 

The  prostatic  secretion  and  the  contents  of  the  seminal  vesicles 
are  obtained  by  placing  the  patient  in  the  knee-elbow  position 
on  a  couch  or  bending  over  the  back  of  a  chair  with  his  hands  on 
the  seat,  and  systematically  massaging  these  organs  towards  the 
middle  line,  and  finally  stripping  the  prostatic,  bulbous,  and  penile 
urethra  from  behind  forwards.  The  secretion  is  prepared  in 
a  similar  manner  to  the  urethral  discharge  (p.  599).  The  usual 
methods  of  staining  are  methylene  blue  and  Gram's  stain.  The 
gonococcus  is  Gram- negative.  The  shreds  are  found,  on  micro- 
scopical examination,  to  consist  of  mucus  in  which  are  embedded 
pus  cells  and  epithelial  cells  with  bacteria.  As  the  urethritis 
diminishes,  the  pus  cells  become  fewer  and  the  epithelial  cells 
proportionally  greater  in  numbers.  Gonococci  are  found  adhering 
to  the  epithelial  cells,  within  the  leucocytes,  and  free.  They  have 
the  characters  already  described.  In  old-standing  cases  they  m-ay 
be  very  scanty  in  numbers  and  difficult  to  find,  and  many  films 
must  be  examined  lest  they  be  overlooked.  In  many  cases  they 
have  completely  disappeared  and  have  been  replaced  by  a  mixed 
infection  of  other  bacteria.  The  gonococcus  may  persist  for  as 
long  as  three  years  or  even  longer  after  the  original  infection. 

An  aseptic  non-gonococcal  discharge  is  occasionally  observed 
as  a  final  stage,  but  is  rare. 

Should  the  examination  fail  to  reveal  the  presence  of  the  gono- 
coccus, an  artificial  urethritis  should  be  created  by  injecting  a  few 
drops  of  silver  nitrate  solution  (1  per  cent.)  into  the  urethra. 
When  a  reaction  follows,  in  a  few  hours  or  after  a  day,  the  dis- 
charge should  be  examined,  and  the  gonococcus  may  now  be 
present. 

5.  Urethroscopic  examination.  —  The  urethroscope,  the 
methods  of  urethroscopy,  and  the  appearances  of  the  normal 
urethra  have  already  been  described  (p.  556). 

The  anterior  urethra  is  first  inspected.     In  the  more  pronounced 


xLviiJ  GLEET:    DIAGNOSIS  613 

and  recent  forms  of  chronic  urethritis  the  mucous  membrane  is 
swollen  and  bright  or  deep  red.  It  has  lost  some  of  its  refractile 
power  and  appears  dull  and  is  less  easily  illuminated,  bleeds 
easily,  and  the  radiating  folds  are  heavier  and  less  supple.  The 
striation,  well  marked  in  the  normal  urethra,  is  obscured  and 
may  have  disappeared.  Gross  forms  of  ulceration  are  wanting, 
but  there  are  areas  in  which  the  surface  has  a  granular  appear- 
ance from  denudation  of  the  epithelium.  The  openings  of  the 
lacunae  are  slit-like  and  the  lips  puffy,  and  as  the  urethroscope 
tube  passes  over  them  a  little  pus  wells  out.  These  appearances 
may  extend  along  the  whole  anterior  urethra,  or  may  be  confined 
to  the  bulbous  urethra  or  occur  in  patches  at  any  part  of  the 
anterior  urethra. 

In  a  less  severe  form  the  inflammation  is  found  in  patches 
surrounding  inflamed  lacunse.  The  openings  of  the  lacunse  are 
large  and  red,  and  a  small  point  of  pus  may  exude  from  them. 

In  some  cases  the  openings  of  one  or  several  lacunse  become 
blocked  and  the  contents  accumulate,  forming  reddish-yellow 
beads  projecting  from  the  roof  of  the  urethra,  a'nd  best  seen  under 
air-distension. 

In  more  chronic  conditions  there  are  patches  of  induration  of 
varying  extent.  The  mucous  membrane  is  dull  red  and  raised, 
and  has  lost  its  suppleness  and  texture.  On  withdrawing  the 
urethroscope  such  a  patch  distorts  the  star-shaped  folds,  so  that 
one  segment  of  the  field  is  occupied  by  a  broad,  thick,  tough  fold, 
and  the  central  depression  of  the  urethra  is  displaced  towards  the 
opposite  side. 

As  organization  of  this  tissue  takes  place  the  surrounding 
mucous  membrane  is  dragged  upon  and  raised  up,  and  a  fine 
ridge  appears,  the  first  stage  of  an  annular  stricture. 

In  the  prostatic  urethra  congestion  of  the  prostatic  sinuses  is 
present.  The  verumontanum  is  thickened  and  increased  in  size, 
and  frequently  distorted  in  old-standing  cases.  The  swollen, 
inflamed  orifice  of  the  sinus  pocularis  can  be  distinguished  when 
this  is  the  seat  of  residual  infection. 

Treatment. — When  the  urethritis  has  followed  an  acute  attack 
of  comparatively  recent  date  the  lesions  are  usually  superficial, 
and  are  frequently  confined  to  the  prostatic  urethra.  The  most 
useful  method  of  treatment  is  irrigation  of  the  whole  length  of 
the  urethra  and  the  bladder  with  weak  solutions  of  astringent 
antiseptics,  such  as  nitrate  of  silver,  1  in  10,000,  cautiously  in- 
creased to  1  in  1,000.  This  may  be  carried  out  by  hydrostatic 
pressure. 

Janet's  method  of  urethral  irrigation. — The  patient  lies  on 


614  THE   URETHRA  [chap. 

a  couch  on  a  waterproof  sheet  with  a  basin  between  the  thighs, 
or  stands  over  a  basin.  An  irrigator  containing  the  fluid,  which 
must  be  warm,  is  raised  to  the  height  of  about  3  ft.  above  the 
level  of  the  pelvis.  A  glass  urethral  nozzle  is  attached  to  the 
rubber  tubing  and  grasped  with  the  right  hand,  so  that  the 
rubber  tube  is  controlled  immediately  behind  it  with  the  third 
and  fourth  fingers. 

The  penis  is  seized  with  the  left  hand.  A  stream  of  fluid  is 
flrst  directed  against  the  meatus,  and  then  the  terminal  portion 
of  the  urethra  is  washed,  and  eventually  the  whole  anterior  urethra, 
fluid  being  allowed  to  distend  the  canal  gently  and  then  escape. 
The  patient  is  now  directed  to  relax  all  the  urethral  muscles  and 
breathe  deeply ;  the  flow  is  controlled  by  pressure  of  the  fingers, 
and  allowed  to  pass  slowly  at  first,  and  gradually  with  greater 
volume  and  force,  until  the  resistance  of  the  compressor  urethrse 
is  overcome  and  the  fluid  flows  through  the  prostatic  urethra  into 
the  bladder.  When  the  bladder  is  distended  the  patient  passes 
the  contents  and  the  irrigation  is  repeated.  Several  pints  of  fluid 
are  used  at  each  sitting.  Some  practice  on  the  part  of  the  patient 
may  be  required  before  the  urethral  sphincter  can  be  readily 
relaxed.  The  injection  of  20  minims  of  cocaine  solution  (1  per 
cent.)  by  means  of  a  pipette  or  Guyon's  syringe  will  overcome 
spasm  in  difiicult  cases.  Should  this  prove  unsuccessful  a  soft 
rubber  catheter  may  be  passed  through  the  compressor  urethrse, 
the  fluid  flowing  through  this  into  the  bladder.  On  withdrawal 
of  the  catheter  the  anterior  urethra  is  washed,  and  the  patient  then 
empties  the  bladder,  washing  the  whole  length  of  the  urethra. 
The  irrigations  are  made  daily  or  every  second  day. 

Instillations. — In  chronic  urethritis  confined  to  the  posterior 
urethra  instillations  of  stronger  astringents  and  antiseptics  are 
useful.  Nitrate  of  silver  solution  is  employed  usually  in  1  or  2 
per  cent,  strength,  but  occasionally  stronger  solutions,  3  or  4  per 
cent.,  may  be  used.  Zinc  sulphate  solution,  2  to  4  per  cent.,  is 
efiicacious  in  some  cases. 

The  instillations  are  made  with  a  Guyon's  syringe  or  an  Ultz- 
mann's  syringe,  and  are  repeated  once  a  week.  The  catheter  of 
one  of  these  syringes  is  passed  until  the  point  is  felt  to  hesitate  at 
the  membranous  urethra.  It  now  passes  on  into  the  prostatic 
portion,  and  the  solution  is  then  injected.  This  method  should 
be  used  with  great  care.  There  is  a  danger  of  prostatitis  and  of 
epididymitis  following  the  incautious  use  of  strong  solutions  in 
unsuitable  cases. 

Applications  through  the  urethroscope. — In  the  anterior 
urethra  patches  of  chronic  inflammation  may  be  treated  by  pass- 


XLVIl] 


GLEET:    TREATMENT 


615 


ing  the  urethroscope  tube  and  applying  a  solution  of  nitrate  of 
silver  (2-4  per  cent.)  to  the  diseased  area  by  means  of  a  pledget 
of  cotton-wool  on  a  carrier.  This  is  allowed  to  remain  in  contact 
with  the  mucous  membrane  for  one  or  two  minutes,  and  the  excess 
of  solution  mopped  up  with  a  dry  pledget  of  wool.  Occasionally 
a  specially  resistant  spot  may  be  cured  by  touching  it  with  a  fine 
head  of  solid  silver  nitrate  melted  on  to  a  fine  wire.  The  same 
treatment  may  be  applied  to  the  prostatic  urethra  and  to  the 
orifice  of  the  sinus  pocularis  through  a  prostatic  tube. 

Inflamed  and  blocked  lacunae  are  treated  by  cauterization  with 
a  fine  urethral  electro-cautery  or  slit  with  a  fine  urethral  knife. 


Fig.  188. — Kollmann's  dilators. 

A,  Curved,  for  prostatic  urethra.     B,  Curved  and  straight,  for  prostatic  and  bulbous  urethra. 
C,  Straight,   for  anterior  urethra. 

Dilatation. — 1.  In  chronic  induration,  apart  from  the  presence 
of  a  stricture,  dilatation  by  large  metal  sounds  (12-14,  14-16)  is  of 
great  value.  If  necessary,  the  meatus  should  be  slit  in  order  to  ac- 
commodate the  sounds,  which  should  be" passed  once  or  twice  a  week. 

2.  This  dilatation  may  be  followed  by  irrigation  by  Janet's 
method  (p.  613). 

3,  The  combination  of  dilatation  with  the  application  of  anti- 
septic and  stimulating  ointments  has  long  been  used.  The  oint- 
ment may  be  smeared  on  the  ordinary  smooth  conical  metal  sound, 
or  a  specially  constructed  sound  with  longitudinal  grooves  (four 
to  six)  in  which  the  ointment  is  used.  An  ointment  suggested 
by  Mena  has  the  following  composition  :  Bals.  peruv.  2,  argenti 
nitras  1,  cera  flav.  2,  butyr.  cacao  100. 


616  THE   URETHRA  [chap. 

4.  KoUmann's  dilators. — A  number  of  forms  of  graduated 
dilator  have  been  introduced,  the  most  perfect  of  which  is  that  of 
Kollmann  (Fig.  188).  It  consists  of  smooth  metal  strips  (four  in 
number),  which  are  separated  by  turning  a  screw  in  the  handle,  the 
amount  of  dilatation  being  indicated  by  a  dial.  Straight  dilators 
are  used  for  the  anterior,  and  curved  for  the  posterior  urethra.  The 
dilator  is  smeared  with  lubricant  and  introduced.  In  the  earlier 
dilators  a  fine  rubber  covering  was  used  to  prevent  injury  of  the 
mucous  membrane  by  the  blades,  but  no  rubber  covering  is  re- 
quired for  the  most  recent  models.  The  screw  is  gently  turned  to 
28  or  30  at  first,  and  this  is  maintained  for  ten  minutes.  Later, 
higher  numbers  are  reached  and  the  length  of  time  is  extended. 
The  dilatation  is  performed  once  or  twice  a  week. 

5.  Irrigating  dilators. — Provision  is  made  in  the  instrument 
for  irrigation  of  the  urethra  with  a  stream  of  weak  antiseptic 
(silver  nitrate,  1  in  10,000)  during  the  dilatation. 

Urethritis  and  Marriage 

This  subject  assumes  a  serious  importance  owing  to  the  grave 
results  of  gonococcal  infection  in  the  female. 

It  is  necessary  to  demonstrate  the  absence  of  the  gonococcus. 
After  an  acute  gonorrhoeal  urethritis,  when  the  discharge  has 
entirely  disappeared,  and  the  urine  is  clear  and  contains  no  shreds, 
there  is  a  possibility  that  gonococci  may  still  lurk  in  the  lacunae 
and  in  the  prostate,  and  that  they  may  reappear  on  connection. 
The  tests  that  have  already  been  described  must  be  carefully 
employed  {see  p.  610). 

The  examination  may  be  summarized  as  follows : — 

1.  Examination  of  the  deposit  of  centrifugalized  morning 
urine. 

2.  Urethroscopic  examination  of  the  anterior  and  posterior 
urethra. 

3.  Examination  of  the  urine  passed  or  of  washing  of  the  urethra 
after  dilatation  by  sounds  or  dilators. 

4.  Examination  of  the  'contents  of  the  prostate  and  seminal 
vesicles  obtained  by  massage  from  the  rectum. 

5.  Examination  of  an  artificial  discharge  produced  by  instilla- 
tion of  nitrate  of  silver  solution  (1  per  cent.). 

6.  Examination  for  discharge  after  the  injection  of  gonococcal 
vaccine. 

Should  these  methods  fail  to  demonstrate  the  gonococcus,  a 
delay  of  at  least  two  months  should  still  be  insisted  upon  before 
marriage  is  permitted. 

In  chronic  urethritis  with   the  presence  of   gonococci,  similar 


xLvii]  URETHRITIS    AND    MARRIAGE  617 

means  should  be  adopted  to  ascertain  if  the  gonococcus  is  present, 
and  a  longer  period  (four  to  six  months)  is  necessary  after  the 
diplococcus  has  disappeared. 

In  non-gonococcal  infections  the  same  rigid  care  need  not  be 
taken.  The  urethritis  should  be  treated,  and  discharge  must  have 
disappeared  before  marriage  can  be  allowed,  but  the  presence  of 
a  few  flakes  in  clear  urine  cannot  be  looked  upon  as  a  bar  to 
marriage  provided  the  gonococcus  can  be  excluded. 


CHAPTER  XLVIII 
URETHRAL  CALCULUS-FOREIGN  BODIES 

CALCULUS 

There  are  two  varieties  of  stone  in  the  urethra — (1)  primary, 
when  the  calculus  originates  in  the  urethra  ;  (2)  secondary,  when 
a  migrating  calculus  is  arrested  in  the  canal. 

Etiology. — Primary  calculi  take  origin  in  phosphatic  crusts 
deposited  upon  a  raw  surface  in  the  urethra.  This  is  more  likely 
to  occur  when  stricture  is  present  and  the  urine  tends  to  "  hang  " 
in  the  tube.  A  small  portion  of  phosphatic  deposit  detached 
from  such  a  surface  forms  the  nucleus  of  a  stone  on  which  fresh 
deposit  accumulates.  I  have  seen  a  case  in  which  a  ring-like 
urethral  calculus  formed  after  rupture  of  the  urethra  (p.  591). 

Calculi  which  form  in  pockets  connected  with  the  urethra 
have  a  similar  origin.  In  the  anterior  urethra  the  diverticula  may 
be  congenital  or  result  from  operation,  stricture,  or  the  rupture  of 
cysts  or  abscesses.  Many  cases  of  prostatic  calculi  are  of  this 
nature,  and  a  history  can  be  obtained  of  a  prostatic  abscess  which 
ruptured  into  the  urethra  at  a  previous  date. 

Secondary  calculi  are  passed  from  the  bladder. 

In  the  old  operation  of  lithotrity  the  fragments  of  the  crushed 
stone  were  passed  by  the  patient,  and  might  become  arrested  and 
form  the  nucleus  of  a  urethral  calculus. 

Pathology. — Primary  urethral  calculi  are  always  phosphatic. 
They  are  composed  of  calcium  and  magnesium  phosphate,  or 
calcium  carbonate,  and  sometimes  ammonio-magnesium  phos- 
phate. Secondary  calculi  contain  uric  acid,  calcium  oxalate,  or 
other  ingredients  found  in  renal  and  vesical  calculi.  This  forms 
the  nucleus,  usually  of  small  size,  around  which  phosphates  are 
deposited  in  layers. 

Lieblein  and  Finsterer  have  described  calculi  composed  of  urates, 
with  or  without  phosphates  or  oxalates,  which  they  considered 
from  the  absence  of  symptoms  of  descent  to  have  been  formed 
in  situ;  and  Monsarrat  made  similar  observations  in  regard  to 
three  calculi  containing  calcium  oxalate. 

Increase  in  size  is  always  most  extensive  at  the  vesical  end  of 

618 


CHAP.  xLviii]       URETHRAL    CALCULUS 


619 


the  calculus.  As  the  calculus  grows  it  becomes  moulded  to 
the  shape  of  the  urethra,  and  the  urethra  itself  is  gradually 
dilated.  Very  large  calculous  masses  are  occasionally  found. 
These  are  usually  in  the  form  of  two  or  several  calculi,  the  points 
of  contact  being  worn  and  faceted,  the  one  segment  fitting  accu- 
rately into  the  other,  sometimes  in  the  form  of  a  ball-and-socket 
joint.  I  removed  from  the  urethra  of  a  man  aged  50  a  cal- 
culus which  weighed  750  gr.,  measured  4 J  in.  in  length,  and 
consisted  of  two  pieces  faceted  at  the  contiguous  surfaces.  The 
entire  mass  formed  a  cast  of  the  dilated  prostatic  urethra,  a 
narrow  neck  at  the  membranous  portion,  and  a  long  expansion 


Fig.  189. — Urethral  calculus  in  two  pieces,  weight  750  gr., 
which  formed  a  cast  of  urethra. 

On  the  right  is  seen  a  cast  of  the  dilated  prostatic  portion,  then  a  constriction  corresponding 
to  the    membranous  portion  ;    and  to  the  left  a  cast  of  the  bulbous  urethra  as  far  as  the  com- 
mencement of  the  penile  portion. 

filling  the   bulbous  urethra  as  far  as  the  peno-scrotal  junction. 
(Fig.  189.) 

Multiple  stones  are  due  to  fracture  of  a  single  stone,  and  a 
nucleus  only  exists  in  one  of  them.     When  a  calculus  occupies 
the   prostatic  urethra  and   projects  into  the   bladder,  phosphatic 
material  is  rapidly  deposited  on  the  intravesical  portion,  so  that. 
an  umbrella-  or  mushroom-like  form  is  given  to  the  stone. 

Calcuh  may  lie  in  any  part  of  the  canal.  According  to  Englisch, 
the  calculus  is  lodged  in  the  membranous  (and  prostatic)  portion  in 
42  per  cent.  ;  in  the  bulbous  urethra  in  18-6  per  cent.  ;  in  the 
scrotal  and  penile  urethra  in  28-2  per  cent.  ;  and  in  the  fossa 
navicularis  in  11-2  per  cent.  In  the  majority  of  cases  one  or  several 
strictures   of   the   urethra   coexist.     The   calculus   frequently   lies 


620  THE   URETHRA  [cHAr. 

behind  a  stricture,  or  between  two  strictures.  Urinary  fistulae 
are  occasionally  present  in  the  perineum. 

I  have  operated  in  a  case  where  a  large  stone  occupied  the 
prostatic  urethra.  There  was  congenital  stenosis  of  the  bulbous 
urethra  and  a  large  congenital  urethro -rectal  fistula  opening  behind 
the  stricture. 

A  calculus  may  lie  in  a  pouch  communicating  with  the  anterior 
urethra  either  in  its  bulbous  or  penile  portions,  or  in  a  pocket  in 
the  substance  of  the  prostate.  A  portion  of  the  calculus  usually 
projects  into  the  urethra,  and  may  be  joined  to  the  extra-urethral 
portion  by  a  neck.  A  groove  is  present  on  the  urethral  portion, 
forming  a  gutter  for  the  passage  of  the  urine. 

Symptoms. — A  migrating  calculus  most  frequently  becomes 
impacted  in  the  urethra  in  children,  but  the  accident  may  occur 
at  any  age. 

1.  Impaction  of  a  migrating  stone. — In  adults  there  is  fre- 
quently a  preliminary  attack  of  renal  colic  when  the  stone  is  pass- 
ing down  the  ureter,  followed,  it  may  be,  by  a  quiescent  interval 
of  several  days.  In  children  this  is  usually  absent.  The  patient 
feels  something  enter  the  urethra  during  micturition,  and  then 
there  are  sudden  arrest  of  the  stream,  intense  pain,  and  continuous 
ineffectual  straining,  with  the  passage  of  a  few  drops  of  blood. 
Complete  retention  of  urine  not  infrequently  follows.  On  pass- 
ing a  metal  catheter  to  relieve  the  obstruction,  the  compressor 
urethrse  is  found  spasmodically  contracted,  and  the  click  of  a 
stone  is  felt  in  the  prostatic  urethra.  The  instrument  may  push 
the  calculus  before  it  into  the  bladder,  or  may  pass  alongside  it. 
The  calculus  may  be  felt  from  the  rectum.  Recurrent  attacks 
of  difficult  micturition,  or  even  complete  retention,  occur  when 
the  stone  becomes  impacted  behind  a  stricture  of  the  bulbous  or 
penile  urethra.  Here  the  calculus  can  be  felt  on  palpating  the 
perineum  or  the  penile  urethra.  Occasionally  the  stone  becomes 
impacted  in  the  fossa  navicularis,  and  can  be  readily  felt. 

2.  Stone  in  the  urethra. — When  the  calculus  has  been  pre- 
sent in  the  urethra  for  a  considerable  time,  it  may  have  reached 
a  large  size  without  causing  great  inconvenience.  In  a  case  under 
my  care  the  stone  had  been  thirty  years  in  the  urethra.  There 
are  pyuria  and  usually  a  urethral  discharge,  difficult  micturition 
with  a  small  distorted  stream,  frequent  micturition,  and  discom- 
fort. Urinary  fistulse  may  be  present.  Frequently  there  is  a 
stricture,  to  which  the  symptoms  of  obstruction  may  be  ascribed. 

On  palpation  of  the  penile  or  bulbous  urethra,  or  by  rectal 
examination,  the  stone  can  be  felt  in  either  the  anterior  or  the 
posterior    urethra.     On    examination    with    the    urethroscope    a 


xLviii]  URETHRAL    CALCULUS  621 

greyish- white  stone  can  be  seen  (Plate  40,  Fig.  3),  and  a  metal 
sound  is  arrested  with  a  metallic  click.  If  several  calculi  are 
present,  characteristic  grating  can  be  felt. 

The  X-rays  show  a  shadow  in  the  line  of  the  urethra.  (Plate 
39  Fig.  2.) 

Treatment. — A  migrating  calculus  of  the  prostatic  urethra 
is  usually  pushed  back  into  the  bladder  on  passing  a  catheter. 
It  should  then  be  either  evacuated  with  a  lithotrity  cannula  and 
bulb,  or  crushed  and  removed.  If  the  calculus  is  not  pushed  back 
into  the  bladder  with  the  catheter,  the  instrument  should  be  tied 
in  place  for  a  few  days,  and  on  removing  it  the  stone  will  probably 
be  expelled.  A  calculus  at  the  fossa  navicularis  can  usually  be 
coaxed  out  of  the  urethra  with  a  bent  probe.  If  necessary,  the 
meatus  should  be  slit  downwards  to  allow  of  its  removal. 

A  fixed  calculus  of  the  prostatic  urethra  should  be  removed 
by  median  perineal  section,  and  if  it  is  embedded  in  a  sacculus, 
care  should  be  taken  to  destroy  the  wall  of  this  pocket.  The 
bladder  should  then  be  searched  for  vesical  calculi,  and  these 
removed  with  lithotomy  forceps.  In  the  bulbous  urethra  an 
extensive  operation  may  be  necessary  for  the  removal  of  large 
calculi,  and  when  fistulse  are  present  a  plastic  operation  will  be 
required  at  a  later  date. 

Small  calculi  in  the  penile  and  bulbous  urethra  can  sometimes 
be  removed  by  urethral  forceps  when  no  stricture  is  present ;  but 
when  they  lie  behind  a  stricture  external  urethrotomy  is  neces- 
sary, the  stricture  being  cut  at  the  same  time. 

LITERATURE 

Court,  Lancet,  1896,  i.  1561. 

Englisch,  Arch.  /.  klin.  Chir.,  Bd.  Ixxii.,  p.  489. 

Fenwick,   Trans.  Path.  Soc,  1890,  vol.  xli. 

Kaufmann,   Krankheiten  der  mdnnlichen  Harnrohre  und  der  Penis.     1886. 

Korn,  Inaugural  Dissertation,  Leipzig,  1865. 

Lieblein,  Beitr.  z.  klin.  Chir.,  1896,  p.  141. 

Monsarrat,  Brit.  Med.  Journ.,  1912,  i.  3. 

Pasteau,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1901,  p.  416. 

Ziessl,   Ueber  die  Steine  in  der   Harnrohre  des  Mannes.     Stuttgart,  1883. 

FOEEIGN  BODIES  IN  THE  URETHRA 
A  large  variety  of  foreign  bodies  may  be  found  in  the  urethra 
of  erotic  individuals,  and  portions  of  surgical  instruments  may 
be  accidentally  left  in  the  canal  during  operations.  The  following 
is  a  selection  :  Large  jet  button,  pipe-stem,  glass  rod,  hat-pin,  hair- 
pin, needle,  portion  of  wood,  pencil,  rubber  tube,  feather,  blade  of 
straw,  roll  of  paper,  coin,  portion  of  a  catheter  or  bougie.  Poucet 
describes  the  case  of  an  Arab  who  hid  in  his  urethra  two  gold 
chains,  a  small  cross,  the  handle  of  a  cup,  two  pieces  of  bone,  two 


622  THE  URETHRA  [chap,  xlviii 

fragments  of  teeth,  a  pearl,  and  a  portion  of  whetstone.  Frag- 
ments of  bone  may  penetrate  and  become  lodged  in  the  urethra,  in 
fracture  of  the  pelvis,  or  osteitis  of  the  pelvic  bones. 

Symptoms. — The  foreign  body  does  not  usually  remain  for 
long  in  the  urethra.  Either  it  is  forced  out  by  the  urine  or  re- 
moved by  the  surgeon,  or  it  may  pass  backwards  into  the  bladder. 

When  it  remains  in  the  urethra  there  is  a  purulent  discharge, 
pain,  burning,  and  haemorrhage,  increased  by  erection.  Frequent 
micturition,  difficulty,  dribbling,  and  sometimes  complete  reten- 
tion occur.  When  alkaline  cystitis  is  present  the  foreign  body 
is  quickly  encrusted  with  phosphates.  Periurethritis  and  peri- 
urethral abscess  may  result. 

The  foreign  body  is  usually  lodged  in  the  fossa  navicularis  or 
the  bulbous  urethra,  rarely  in  the  prostatic  urethra,  or  partly  in. 
the  prostatic  urethra  and  partly  in  the  bladder. 

Diagnosis. — The  patient  frequently  conceals  the  fact  that  he 
has  introduced .  a  foreign  body,  and  the  diagnosis  is  made  on 
palpation  of  the  urethra  or  on  passing  a  sound  or  urethroscope  tube. 

Treatment. — The  foreign  body  may  be  swept  out  by  the 
stream  of  urine  if  the  meatus  is  compressed  during  the  flow  and 
then  suddenly  relaxed.  A  long,  firm  body  may  be  pressed  out 
from  the  perineum  or  penis.    Meatotomy  is  frequently  necessary. 

A  pin  with  round  head  lies  in  the  urethra,  with  the  head  bladder- 
wards  and  the  point  buried  in  the  mucous  membrane.  The  point 
should  be  manipulated  through  the  skin  and  the  pin  drawn  out. 
The  head  is  then  reversed,  and  pushed  towards  the  meatus  until 
it  projects  from  it. 

Small  objects  or  portions  of  a  catheter  may  be  withdrawn  by 
means  of  long,  fine  urethral  forceps,  and  a  magnet  has  been  used 
to  remove  an  iron  foreign  body  (Hofmeister). 

The  urethroscope  is  used  to  diagnose  and  also  to  remove 
foreign  bodies,  urethral  forceps  being  passed  along  a  large  urethral 
tube.  If  these  measures  fail,  external  urethrotomy  should  be 
performed  and  the  foreign  body  removed.  When  the  foreign  body 
lies  in  the  prostatic  urethra  it  will  be  easier  to  push  it  back  into 
the  bladder  and  deal  with  it  as  a  foreign  body  of  the  bladder. 

LITERATURE 

Brown,   N.Y.  Med.   Journ.,  July  7,  1900. 

Ebermann,    Centralhl.  f.  d.  Krankh.  d.  Harn-  u.  Sex.-Org.,  1895,  iv.  8. 

Gannau,   Brit.  Med.   Journ.,  May  2,  1896. 

Goldberg,  Centralhl.  f.  d.  Krankh.  d.  Harn-  u.  Sex.-Org.,  1897,  p.  113. 

Hawley,   Brit.  Med.   Journ.,  March  17,  1900. 

Poucet,  Gaz.  Hebdom.  de  Med.  et  de  Chir.,  1893,  p.  247. 

Tousey,  Med.  Bee,  May  2,  1896. 

Wayland,  Brit.  Med.   Journ.,  1896,  p.  1033. 

Wilson,  Brit.  Med.   Journ.,  Feb.  24,  1900. 


CHAPTER  XLIX 
STRICTURE  OF  THE  URETHRA 

Stricture  of  the  urethra  is  congenital,  inflammatory,  or  trau- 
matic.    Congenital  stricture  has  already  been  described  (p.  572). 

The  normal  urethra  is  a  collapsed  tube  with  elastic  and  con- 
tractile walls.  In  stricture  the  wall  loses  its  elasticity  and 
becomes  rigid. 

Etiology.  —  The  female  urethra  is  very  rarely  affected. 
Acquired  stricture  has  been  observed  in  male  infants,  but  in  the 
great  majority  of  cases  the  age  is  between  20  and  40. 

The  most  frequent  causes  of  stricture  are  traumatism  and 
chronic  inflammation,  and  the  latter  is  the  more  common. 

The  chronic  urethritis  which  causes  a  stricture  is  gonorrhoeal 
in  origin  in  from  90  to  95  per  cent,  of  cases  (Antal).  Martens 
found  that  129  out  of  186  cases  of  stricture  were  of  this  nature. 
The  urethritis  is  not  necessarily  severe  in  the  acute  stage,  but 
IS  prolonged  in  a  chronic  form.  Any  condition  which  tends  to 
prolong  the  inflammation  in  chronic  urethritis,  such  as  a  narrow 
meatus,  phimosis,  hypospadias  with  contracted  meatus,  injudicious 
treatment  by  means  of  strong  injections,  alcohol,  and  exposure, 
acts  as  a  predisposing  cause.  Rarely,  chronic  urethritis  due  to 
tuberculosis  of  the  urethra  or  diabetes  produces  stricture.  SyphiUs 
has  been  known  to  cause  stricture  in  the  tertiary  stage,  or  stricture 
may  follow  a  urethral  chancre  of  the  fossa  navicularis.  Non- 
gonococcal urethritis  rarely  causes  stricture,  as  the  lesions  are 
superficial. 

Individual  idiosyncrasies  exist  in  regard  to  the  development 
of  thick,  dense  strictures  of  the  urethra,  and  the  alcoholic  habit, 
exposure  to  a  hard  climate,  and  neglect  of  regular  treatment  play 
an  important  role. 

Pathological  anatomy. — In  traumatic  stricture  fibrous  tissue 
develops  in  the  space  between  the  severed  ends  of  the  ruptured 
urethra.  The  extent  of  this  depends  upon  the  distance  between 
the  ends  of  the  urethra  and  upon  the  subsequent  destruction  of 
tissue  by  necrosis  from  the  injury  or  sloughing  from  septic  com- 
plications.   The  lesion  develops  rapidly  and  is  single.    Occasionally 

023 


624  THE   URETHRA  [chap. 

there  is  a  thin,  supple  band  involving  the  mucous  membrane, 
but  more  often  there  is  a  thick,  tough,  sharply  defined  mass  of 
fibrous  tissue  involving  the  mucous  and  submucous  coats  and  the 
cavernous  tissue,  and  sometimes  also  the  perineal  tissues  and 
skin.    The  narrowed  lumen  is  eccentric  and  irregular. 

Gonorrhceal  stricture  is  usually  multiple.  Of  100  cases  of 
stricture  examined  by  urethroscope  and  bougie,  3  were  traumatic 
and  single,  and  the  remaining  97  cases  were  gonorrhoeal.  Of  these, 
23  were  single,  42  had  two  strictures,  27  had  three  strictures,  and 
5  had  four  strictures. 

The  part  most  frequently  affected  (72  per  cent.)  is  the  bulbous 
urethra.  Strictures  of  the  penile  urethra  alone  are  comparatively 
uncommon,  only  6  per  cent,  being  situated  between  1  and  3J  in. 
from  the  meatus.  Multiple  strictures  affecting  both  the  penile 
and  the  bulbous  urethra  are,  however,  more  common  (22  per 
cent.).  The  prostatic  urethra  is  very  rarely  affected  in  gonor- 
rhoea! stricture. 

In  explanation  of  the  majority  of  strictures  occurring  in  the 
bulbous  urethra  5  or  5^  in.  from  the  meatus,  it  has  been  held  that 
the  bulbous  urethra  is  the  most  dependent  part  of  the  fixed  curve 
of  the  urethra,  and  here  the  discharge  of  a  gonorrhoeal  urethritis  will 
collect.  But  in  the  recumbent  position  this  is  not  the  most  depen- 
dent part  of  the  curve  and  there  is  not  necessarily  any  collection 
of  discharge  at  this  part.  I  hold  the  view  that  the  floor  of  the 
bulbous  urethra  just  in  front  of  the  membranous  opening  is  the 
point  of  the  fijced  curve  on  which  the  full  force  of  the  stream  of 
urine  impinges  when  the  bladder  is  emptied,  and  in  acute  gonor- 
rhoeal urethritis  damage  is  produced  by  this  force.  Excessive 
infiltration  occurs,  and  later  stricture  develops.  Analogy  may 
be  drawn  with  the  frequent  localization  of  disease  to  the  arch  of 
the  aorta. 

When  multiple  strictures  are  present  they  may  be  distributed 
over  almost  the  whole  length  of  the  anterior  urethra,  but  the 
parts  of  the  canal  lying  between  them  are  not  cicatricial.  Exten- 
sive fibrosis  of  the  mucous  membrane  may,  however,  be  found, 
the  strictured  part  measuring  an  inch  or  more,  and  in  rare  cases 
almost  the  whole  length  of  the  anterior  urethra  appears  to  be 
sclerosed.  It  is  rare  that  the  lumen  is  entirely  obliterated,  but 
such  cases  have  been  recorded.  Short  of  this,  the  size  of  the 
stricture  varies  from  a  lumen  admitting  a  bristle  to  a  fine  linear 
fibrous  ring  which  very  slightly  diminishes  the  lumen  when  the 
canal  is  fully  distended. 

The  stricture  may  be  a  fine  elastic  band  of  fibrous  tissues, 
which  either  involves   the   whole  of  the    circumference  (annular 


XLIX 


STRICTURE:    PATHOLOGY 


625 


stricture,  Fig.  190)  or  one  part — the  floor,  roof,  or  sides  of  the  wall ; 
or  it  may  form  an  isolated  band  stretching  across  the  lumen  (bridle 
stricture).  The  latter  is  usually  produced  from  an  annular  stric- 
ture by  a  false  passage  (Fig. 
191)  being  made  through 
the  stricture  tissue  by  the 
point  of  an  instrument  care- 
lessly handled.  The  false 
passage  lies  below  the  lu- 
men of  the  stricture,  has  a 
calibre  as  large  as  that  of 
the  stricture,  and  is  only 
separated  from  its  lumen 
by  the  bridge  of  tissue 
which  is  named  a  "  bridle." 
In  old-standing  strictures 
the  fibrous  tissue  is  hard, 
tough,  and  avascular  (car- 
tilaginous stricture).  The 
lumen  is  central  or  eccen- 
tric, according  to  whether 
the  fibrous  tissue  develops 
evenly  around  the  whole 
circumference  or  is  more 
abundant  at  one  part.  In 
the  normal  urethra  the 
elastic  walls  are  in  close 
contact ;  in  a  strictured 
urethra  there  is  a  perma- 
nent lumen  at  the  stricture. 
The  histological  changes 
consist  in  proliferation  of 
the  epithelium  and  change 
from  the  transitional  to  a 
squamous  type,  and  scle- 
rosis of  the  subepithelial 
tissue,  so  that  a  dense 
avascular  inelastic  fibrous 
layer  develops.  This  in- 
vades the  submucous  tissue 
and  the  tissue  of  the  cor- 
pus spongiosum. 

The  earliest  stage  is  an 
infiltrated    patch     in     the 
2o 


Fig.  190. — Annular  stricture  of 
the  bulbous  urethra. 


626 


THE   URETHRA 


[chap. 


-X- 


mucosa  in  the  course  of  a  chronic  urethritis.  Sclerosis  of  this 
patch  is  the  commencement  of  the  stricture,  which  increases  by 
circular  traction  on  the  mucous  membrane.     (Plate  40,  Fig.  2.) 

When  the  narrowing  has  progressed  so  far  as  to  cause  obstruc- 
tion to  the  flow  of  urine  the  force  of  the  stream  drags  and  tears  at 

the  stricture  during  micturition, 
and,  I  believe,  keeps  up  and 
increases  the  chronic  inflamma- 
tion that  is  already  present. 
Where  the  lumen  of  the  stric- 
ture is  very  small  and  the 
stricture  tissue  supple,  the 
stream  of  urine  probably  drives 
the  stricture  forwards  and  bal- 
loons it  inside  the  urethra  at 
each  micturition.  In  support 
of  this  view  it  will  be  found 
that  in  multiple  stricture  the 
narrowest  stricture  is  nearest 
the  bladder,  and  this  is  the 
one  which  is  exposed  to  the  full 
force  of  the  stream. 

The  urethra  behind  the 
stricture  shows  chronic  inflam- 
mation and  dilatation.  Vege- 
tations and  ulceration  are  fre- 
quently present. 

The  bladder  muscle  is  hy- 
pertrophied,  and  cystitis  is 
common.  There  may  be  acute 
retention  of  urine,  or  the 
bladder  may  be  chronically  dis- 
tended. It  is,  however,  the 
exception,  apart  from  complete 
retention,  to  find  residual  urine. 
The  ureters,  and  eventually 
the  kidneys,  become  dilated, 
and  ascending  septic  pyelone- 
phritis is  usually  present  in  old-standing  cases. 

Symptoms. — In  stricture  of  large  calibre  the  only  symptom 
may  be  a  persistent  purulent  discharge  (gleet). 

In  stricture  with  small  lumen  other  symptoms  develop.  The 
stream  is  small,  thin,  twisted,  forked,  or  sprayed,  or  it  may  appear 
in  short  jets  or  only  in  drops.     None  of  these  is  characteristic  of 


v. 


Fig.  191. — Stricture  of  the 
bulbous  urethra,  with  re- 
cent false  passage. 


Fig.  1. — Lacunee  and  striation  of  roof  of  normal  urethra. 
(Pp.  554,  560.) 

Fig.  2. — Scar  tissue  in  urethra  in  old-standing  stricture. 
(P.  626.) 

Fig.  3. — Urethroscopic  view  of  stone  behind  stricture  of 
urethra.     (Pp.  621,  628.) 

Fig.  4. — Urethroscopic  view  of  stricture  with  large  false 
passage  on  floor  and  another  on  roof  of  urethra. 
(P.  628.) 


Plate  40. 


xLix]  STRICTURE:   SYMPTOMS  627 

stricture,  although  they  are  frequently  present.  The  projection  is 
feeble ;  instead  of  the  stream  performing  a  full  curve  it  drops 
vertically.  There  may  be  a  pause  before  micturition  commences, 
the  latent  period  lasting  for  a  few  seconds  to  two  or  three  minutes. 
The  patient  strains  to  pass  urine,  and  the  stream,  poor  through- 
out, tails  oft"  at  the  finish  into  a  feeble  dribble. 

Frequent  micturition  is  usually  due  to  chronic  urethritis  of  the 
prostatic  urethra  or  to  cystitis  ;  occasionally,  however,  it  develops 
without  inflammation  being  present. 

Pain  may  be  felt  at  the  seat  of  the  stricture  during  micturition. 
Usually,  however,  the  patient  is  unconscious  of  any  urethral  sensa- 
tion. Pain  at  the  external  abdominal  rings  may  be  due  to  hernia 
from  straining.  In  the  absence  of  this  cause  it  is  caused  by  dila- 
tation of  the  lower  end  of  the  ureter.  Pain  in  the  posterior  renal 
area  is  the  result  of  back  pressure  on  the  Iddney.  The  patient 
may  feel  pain  over  one  kidney  each  time  he  passes  water,  due  to 
loss  of  sphincter  action  of  the  lower  ureter. 

Pain  on  ejaculation  and  reflux  of  semen  into  the  bladder  occur, 
and  are  a  cause  of  sterility. 

Transient  retention  may  occur,  the  patient  being  unable  to 
pass  urine  for  a  few  minutes  to  half  an  hour,  or  even  longer,  and 
then  the  flow  gradually  recommences. 

Acute  total  retention  of  urine  is  caused  by  a  chill,  an  excess 
of  alcohol,  dietetic  indiscretion,  or  sexual  excess.  The  stricture 
is  usually  narrow,  but  not  infrequently  the  calibre  is  compara- 
tively large  (8  or  10  Fr.).  The  patient  complains  of  severe  supra- 
pubic cramping  pain  which  occurs  in  paroxysms  with  intervals 
of  aching.  He  is  pale,  the  skin  often  pale  and  perspiring. 
The  bladder  is  felt  as  an  oval  suprapubic  swelling.  No  urine 
escapes,  or  only  a  few  drops  are  passed  from  time  to  time.  In 
some  cases  there  is  a  remarkable  absence  of  pain,  the  patient 
complains  of  inability  to  pass  water,  and  the  bladder  is  found 
distended. 

Retention  of  urine  in  stricture  is  due  to  spasm  of  the  com- 
pressor urethrae  muscle,  or  to  congestion  of  the  mucous  membrane 
at  the  stricture,  or  to  both  these  factors  combined.  In  a  few 
cases  it  may  result  from  temporary  paralysis  of  the  bladder,  due 
to  cystitis  or  over-distension. 

Incontinence  of  urine  is  observed  in  narrow  strictures  and 
takes  several  forms.  A  small  quantity  of  urine  may  be  retained 
in  the  urethra  behind  the  stricture  and  dribble  away  after  mic- 
turition is  finished.  Some  escape  of  urine  occasionally  takes 
place  on  walking  or  exertion,  from  distension  of  the  urethra  be- 
hind the  stricture  and  weakening  of  the  sphincter.      Involuntary 


628  THE   URETHRA  [chap. 

dribbling  of  urine  is  observed  when  the  bladder  is  chronically 
over-distended. 

In  the  later  stages  of  stricture  chronic  cystitis  is  almost  invari- 
ably present  and  the  bladder  becomes  contracted,  so  that  there 
is  frequent  and  painful  micturition  day  and  night.  In  long- 
standing stricture  dilatation  and  septic  infection  of  the  ureters 
and  kidneys  lead  to  symptoms  of  urinary  septicaemia  and  of  renal 
failure  (p.  133). 

Examination  of  the  urethra. — A  circumscribed  cartilaginous 
stricture  of  the  penile  urethra,  and  occasionally  one  situated  in 
the  bulbous  urethra,  can  be'  felt  on  palpation,  and  is  more  dis- 
tinct when  felt  upon  a  bougie.  Normally  a  25  or  26  Fr.  should 
pass  freely  along  the  urethra  into  the  bladder.  A  large  gum- 
elastic  bougie  (20  or  21  Fr.)  should  be  introduced  gently  along  the 
canal,  and ,  if  it  is  arrested  at  any  point  it  should  be  withdrawn, 
the  distance  from  the  meatus  being  noted  on  the  bougie.  Spasm 
of  the  compressor  rarely  causes  obstruction  which  resists  gentle 
pressure  with  a  bougie  of  this  size.  The  position  of  the  obstruc- 
tion may  be  well  in  front  of  the  membranous  urethra,  so  that 
no  confusion  need  arise. 

The  hard,  inelastic  sensation  given  by  a  cartilaginous  stricture 
is  quite  distinctive. 

A  more  resilient  sensation  is  imparted  by  an  elastic  fibrous 
stricture.  With  practice  it  is  possible  to  distinguish  between 
this  and  obstruction  by  a  fold  of  mucous  membrane.  Smaller 
instruments  are  passed  until  one  which  will  enter  the  lumen  of  the 
stricture  is  found. 

When  the  stricture  is  of  fairly  large  calibre  a  bougie  a  boule 
may  be  used.  This  has  an  acorn  tip.  When  this  is  passed  through 
the  stricture  and  withdrawn  the  shoulder  of  the  acorn  hitches  at 
the  stricture  and  the  length  of  the  strictured  portion  can  be 
measured. 

The  urethroscope  is  of  great  use  in  the  diagnosis  of  stricture. 
After  introducing  the  tube  and  applying  the  lantern,  the  air  pressure 
is  turned  on  and  the  urethra  becomes  inflated.  The  stricture  is 
readily  diagnosed  and  examined  by  this  means  (Plate  40,  Figs.  3,  4) ; 
strictures  of  large  cahbre  are  recognized,  and  through  the  lumen 
of  the  first  stricture  others  may  be  seen.  The  opening  of  the 
membranous  urethra,  which  is  seen  as  an  arch  on  full  distension, 
should  be  distinguished  from  a  stricture. 

Diagnosis. — 1.  Spasm  of  the  com'pressor  urethrcB  (spasmodic 
stricture)  is  caused  by  acute  or  chronic  inflammation  of  the  pros- 
tatic urethra.  The  symptoms  produced  are  difiicult  micturition 
and  increased  frequency,  with  a  varying  amount  of  urethral  dis- 


xLixJ  STRICTURE:   COMPLICATIONS  629 

charge  or  only  urethral  threads  in  the  urine.  The  difficulty  in 
these  cases  is  intermittent  in  character.  At  one  time  the  flow  of 
urine  is  free  and  the  stream  good ;  at  another  time  there  is  diffi- 
culty and  even  retention.  In  organic  stricture  there  is  a  history 
of  gradually  increasing  difficulty  in  micturition. 

On  passing  a  large  bougie  obstruction  is  encountered  at  6  in. 
from  the  meatus,  but  gentle  continuous  pressure  succeeds  in  over- 
coming this  resistance,  and  the  bougie  passes  readily  into  the 
bladder.  Occasionally  the  spasm  is  so  tense  that  it  is  impossible 
to  overcome  it  by  pressure.  The  urethroscope  and  air  distension 
will  then  be  necessary  to  distinguish  between  spasmodic  and 
organic  stricture. 

2.  Malignant  disease  of  the  prostate  gives  rise  to  symptoms  of 
gradually  increasing  obstruction.  The  onset  of  symptoms  in 
stricture  dates  from  a  much  earlier  age  than  that  of  malignant 
disease  of  the  prostate.  The  obstruction  to  the  passage  of  instru- 
ments is  at  the  apex  of  the  prostate,  and  rectal  examination  shows 
a  hard,  nodular  prostate. 

Complications. — The  following  are  complications  that  may 
be  observed  : — • 

1.  Retention  of  urine. 

2.  Septic  complications  : 

Acute  or  chronic  urethritis. 

Periurethral  abscess. 

Acute  or  chronic  prostatitis. 

Epididymitis. 

Cystitis. 

Pyelonephritis  and  pyonephrosis. 

3.  Extravasation  of  urine. 

4.  Fistula. 

5.  Stone  in  the  urethra  and  bladder. 

6.  Malignant  growth  of  the  urethra. 
Retention  of  urine  has  already  been  described. 

In  old-standing  and  neglected  strictures  infection  of  the  urine 
is  almost  invariably  present.  This  is  usually  caused  by  the  use 
of  septic  instruments,  rarely  it  is  hsematogenous  in  origin.  For 
many  years  the  infection  may  be  confined  to  the  urethra  behind 
the  stricture  and  to  the  bladder,  with  the  addition  of  chronic 
prostatitis.  There  are  frequent  micturition,  scalding  and  pain,  and 
the  urine  contains  pus,  mucus,  and  bacteria.  The  temperature  is 
normal,  with  an  occasional  rise  to  100-2°  F.,  or  there  may  be  a 
slight  evening  rise  for  some  months  at  a  time.  At  any  time  acute 
septic  complications  may  supervene,  such  as  periurethral  abscess, 
extravasation  of  urine,   acute  prostatitis,  or  epididymitis,   or  an 


630  THE   URETHRA  [chap. 

ascending  infection  causing  cystitis  and  ascending  pyelonephritis, 
and,  if  obstruction  takes  place  at  the  upper  end  of  the  ureter, 
pyonephrosis  develops.  Fistula  is  a  complication  of  old-standing 
stricture,  and  usually  follows  periurethral  abscess.  Stone  in  the 
urethra  is  a  not  uncommon  complication,  malignant  growth  is  rare. 
These  conditions  will  be  described  later. 

Prognosis. — An  aseptic  inflammatory  stricture  is  amenable 
to  treatment  by  dilatation  and  operation,  and  there  is  a  good 
prospect  of  cure  without  permanent  damage  to  the  urinary  organs. 

Traumatic  stricture  is  less  favourable  to  complete  cure. 

When  sepsis  has  been  introduced  the  prognosis  is  much  less 
favourable,  and  when  it  persists  for  some  years,  untreated  or 
intermittently  treated,  renal  complications  make  the  prognosis 
very  serious. 

Treatment. — The  methods  of  treatment  in  use  are  (1)  dila- 
tation, (2)  operation. 

1.  Dilatation. — Metal  instruments  or  flexible  bougies  of  silk 
or  cotton  web  coated  with  certain  preparations  are  used. 

Metal  instruments  may  have  a  conical  or,  better,  a  bulbous 
end.  The  graduation  'series  slightly  with  the  individual  instru- 
ment-maker, and  the  instruments  bear  two  numbers  which  show 
the  size  at  the  tip  and  at  the  thickest  portion  of  the  shaft.  Metal 
instruments  have  the  advantages  of  withstanding  boiling;  so  that 
they  last  for  many  years  ;  and  of  having  a  smooth,  highly  polished 
surface  that  is  easily  kept  surgically  clean.  They  are  specially 
useful  in  certain  tortuous  strictures,  in  cartilaginous  strictures, 
and  in  strictures  that  have  been  dilated  up  to  a  large  size  and 
still  require  the  occasional  passage  of  an  instrument.  The  lower- 
size  metal  instruments  are  apt  to  injure  the  urethral  mucous  mem- 
brane, and  should  be  handled  with  the  greatest  caution.  When 
not  in  use  metal  instruments  should  be  smeared  with  vaseline 
before  being  laid  aside.  They  should  be  replated  on  the  first  sign 
of  cracking  or  scaling  of  the  nickel. 

Gum-elastic  instruments  or  bougies  should  be  pliable  or  resilient. 
A  good  bougie  tapers  gradually  to  a  bulbous  or  olivary  tip,  and 
presents  no  abrupt  shoulder.  The  shaft  should  be  stiff,  but  the 
half  of  the  instrument  next  the  tip  should  bend  readily  to  the  touch. 

Whalebone  bougies  are  dangerous  instruments  and  should  not 
be  used.  Bougies  are  graduated  according  to  a  French  scale 
which  indicates  the  circumference  in  millimetres,  or  to  an  English 
scale  similar  to  that  used  for  metal  instruments. 

The  French  bougies  possess  the  advantage  of  an  exact  and 
constant  measure,  and  they  ascend  by  finer  gradations  of  size 
(roughly,  3  French  to  2  English). 


xLix]  DILATATION   OF   STRICTURE  631 

Pliable  bougies  are  less  likely  to  damage  the  urethral  mucous 
membrane  than  are  metal  instruments.  They  are  especially  useful 
in  the  smaller  sizes,  and  are  preferable  for  the  dilatation  of  most 
strictures  up  to  21  or  22  Fr.  size.  Beyond  this  size  they  are  stiff 
and  unwieldy,  and  should  be  replaced  by  steel  instruments. 

There  are  three  essentials  to  the  satisfactory  passage  of  an 
instrument  in  a  case  of  stricture  of  the  urethra  ;  the  instrument 
nmst  be  aseptic,  well  lubricated,  and  used  with  a  gentle  hand. 

The  sterilization  of  urethral  instruments  and  the  suitable 
lubricants  are  described  at  p.  562. 

It  is  lack  of  the  third  essential — a  delicate  touch — that  accounts 
for  most  of  the  accidents  which  result  from  the  passage  of  m^ethral 
instruments. 

The  method  of  passing  instruments  is  as  follows  :  The  surgeon 
stands  upon  the  left  side  of  the  recumbent  patient  and  handles 
the  instrument  with  his  right  hand  while  he  manipulates  the  penis 
with  his  left.  (Figs.  101-4,  pp.  358-9.)  In  the  introduction  of  a 
steel  instrument  the  penis  is  grasped  behind  the  glans  by  the  thumb 
and  forefinger,  and  the  tip  of  the  instrument  inserted  into  the 
meatus,  while  the  shaft  of  the  instrument  lies  transversely  across 
the  left  Scarpa's  triangle.  The  handle  of  the  instrument  is  now 
carried  gently  towards  the  patient's  abdomen  and  onwards  to 
the  middle  line,  and  gradually  raised  meanwhile,  so  that  the 
point  drops  downwards  and  backwards.  During  this  manoeuvre 
the  left  forefinger  and  thumb  thread  the  penis  upon  the  instru- 
ment. The  handle  is  lightly  held  between  the  right  forefinger 
and  thumb,  and  the  slightest  hitch  receives  instant  attention. 
If  the  instrument  is  stopped  at  the  stricture,  a  smaller  is  tried 
until  one  is  fomid  that  will  pass.  As  the  point  passes  down 
to  the  bulbous  urethra  the  left  hand  leaves  the  penis  and  the 
fingers  are .  used  to  support  the  perineum.  The  point  of  the 
instrument  passes  into  the  membranous  urethra  as  the  handle 
becomes  vertical  and  swings  downwards,  and  the  left  forefinger 
and  thumb  replace  the  right,  while  the  handle  is  gently  depressed 
between  the  thighs  and  pushed  onwards. 

In  passing  elastic  bougies  the  operator  has  little  power  of 
changing  the  direction  of  the  point  of  the  instrument,  and  the 
passage  of  the  bougie  into  the  membranous  urethra  depends  upon 
its  pliability.  The  penis  is  grasped  behind  the  glans  by  the  thumb 
and  forefinger  of  the  left  hand,  and  kept  on  the  stretch  to  render 
the  urethra  straight  and  obliterate  the  folds  in  its  Myalls.  The 
bougie  is  introduced  and  lightly  held  by  the  corresponding  digits 
of  the  right  hand.  If  the  instrument  engages  in  the  stricture  it 
is  pushed  gently  onwards.     If  the  point  is  arrested  it  is  with- 


632 


THE   URETHRA 


[chap. 


drawn  a  little  and  again  pushed  on.  If  the  attempt  fails  a  smaller 
instrument  should  be  selected,  and  so  on  until  the  size  that  will 
pass  is  reached.  If,  on  the  other  hand,  the  bougie  first  passed 
lies  loose  in  the  stricture,  a  larger  instrument  is  passed  until  the 
size  is  reached  which  is  lightly  gripped  by  the  stricture.  This 
"  fitting  "  a  stricture  with  an  instrument  must  be  distinguished 
from  dilatation  of  the  stricture. 

In  attempting  to  pass  an  instrument  through  a  small  stricture, 


,&J 


Fig.  192. — Passage  of  a  filiform  bougie  through  narrow 
stricture  of  bulbous  urethra. 

Note  the  penis  put  on  the  stretch  with  the  left  hand  and  the  bougie  lightly  held  in  the  right. 

filiform  bougies  are  employed.  (Fig.  192.)  They  should  not  be  used 
until  the  operator  is  satisfied  that  he  is  really  dealing  with  a  small 
stricture,  for  the  point  of  a  filiform  bougie  readily  catches  in  any 
fold  of  mucous  membrane,  and  for  this  reason  may  fail  to  pass 
where  a  stricture  of  comparatively  wide  calibre  is  present,"  or  where 
the  obstruction  is  spasmodic  in  character.  If  the  filiform  bougie 
fails  to  pass,  it  is  withdrawn  and  gently  advanced  again.  On 
further  failure  the  tip  of  the  instrument  is  bent  to  an  angle  and 
the  bougie  again  introduced.  The  face  of  the  stricture  is  now 
searched  by  turning  the  bougie  round  and  testing  the  different 
parts  of  the  circumference.     If  this  manoeuvre  fail  it  should  be 


xLix]  DILATATION   OF  STRICTURE  633 

repeated  with  another  filiform  bougie.  A  syringeful  of  oil  may 
be  injected  into  the  urethra  and  the  meatus  gripped  with  finger 
and  thumb  to  retain  the  oil,  while  at  the  same  time  the  searching 
of  the  face  of  the  stricture  is  continued.  If  this  be  unsuccessful, 
a  number  of  filiform  bougies  should  be  passed  into  the  urethra, 
and  will  engage  in  any  pockets  or  false  passages.  By  trying 
each  bougie  separately,  one  of  them  may  pass  on  through  the 
narrow  opening. 

It  is  sometimes  of  assistance  to  pass  a  large  bougie  down  to 
the  face  of  a  stricture,  and  after  withdrawing  it  to  pass  a  filiform 
one.  In  this  way  the  opening  of  the  stricture  may  be  centred 
and  obstructing  folds  of  mucous  membrane  pushed  aside.  If 
these  attempts  fail  and  no  retention  be  present,  the  patient  should 
be  replaced  in  bed  and  a  brisk  purge  administered.  A  further 
trial  should  be  made  next  day,  and  will  usually  be  successful.  An 
instrument  sometimes  passes  readily  when  the  patient  is  mider 
an  anaesthetic,  after  all  other  methods  have  failed. 

When  several  strictures  are  present,  a  bougie  smaller  than  mil 
fit  the  anterior  strictures  will  be  required  to  negotiate  the  second 
narromng,  for  if  the  instrument  accurately  fits  the  first  stricture 
it  can  only  be  pushed  straight  onwards  without  in  the  least  alter- 
ing the  direction  of  the  point.  A  stricture  which  lies  immediately 
in  front  of  the  membranous  opening  of  the  urethra  will  give  rise 
to  difficulty  in  the  passage  of  instruments,  for  the  membranous 
opening  is  on  the  roof  of  the  bulbous  urethra,  and  the  bougie 
impinges  upon  the  floor  of  the  canal,  which  rises  up  towards  this 
opening.  In  these  cases  it  is  often  necessary  to  resort  to  a  rigid 
metal  instrument,  the  point  of  which  is  more  easily  guided  into 
the  membranous  opening. 

Routine  treatment  of  stricture. — The  majority  of  strictures 
of  the  urethra  are  amenable  to  dilatation  by  instruments.  Dilata- 
tion is  carried  out  in  three  ways :  i.  As  intermittent  dilatation. 
ii.  As  continuous  dilatation,     iii.  As  rapid  dilatation. 

i.  Intermittent  dilatation  is  the  best  method  of  treatment  of 
the  majority  of  strictures,  and  is  carried  out  in  the  following 
manner :  The  diagnosis  of  stricture  having  been  made  by  the 
passage  of  a  bougie  of  large  size  (say  No.  20  Fr.)  down  to  the  stric- 
ture, the  next  step  is  to  "  fit "  the  stricture  with  its  proper  size 
of  bougie.  A  much  smaller  instrument  is  at  once  tried  (say  No.  10 
Fr.),  and,  if  this  fail  to  pass,  successively  smaller  numbers  are 
used,  resorting  at  length,  perhaps,  to  a  fihform. 

When  a  bougie  is  found  that  passes,  it  may  lie  loosely  in  the 
stricture  ;  and  if  so,  a  larger  size  is  passed  until  the  proper  size 
is  reached  which  passes  but  can  be  felt  to   "  fit."     This  size  is 


634  THE   URETHRA  [chap. 

noted,  no  attempt  being  made  to  dilate  the  stricture  by  passing 
larger  instruments.  An  interval  of  four  to  six  days  is  now  allowed, 
and  the  size  which  fitted  the  stricture  is  again  passed,  and  is 
followed  by  the  next  larger  size  in  the  scale,  and  this  is  repeated 
after  a  similar  interval.  The  scale  is  thus  gradually  ascended  until 
the  size  of  the  stricture  has  reached  21  or  22  Fr.  Above  this  size 
the  gum-elastic  bougies  become  too  rigid  and  too  difficult  to  guide, 
and  steel  instruments  should  be  employed. 

During  the  ascent  of  the  scale  the  interval  between  the  in- 
strumentations should  gradually  be  extended.  At  14  Fr.  a  week 
may  intervene,  at  18  Fr.  a  fortnight,  at  20  Fr.  three  weeks,  and 
with  the  larger  steel  bougies  (12-14,  13-15,  14-16)  a  month  should 
elapse.  If  all  goes  well  this  will  be  extended  to  two  months, 
three  months,  and  finally  the  patient  will  call  once  in  six  months 
or  once  a  year  to  have  an  instrument  passed. 

No  absolute  rule  can  be  laid  down  as  to  the  largest  size  to 
which  the  urethra  should  be  dilated.  The  natural  size  of  the 
canal  varies  in  different  individuals.  If  necessary,  the  meatus 
should  be  incised  in  order  to  let  large-sized  bougies  pass.  In 
most  individuals  the  urethra  should  admit  a  bougie  of  22  Fr. 
calibre,  and  it  is  advisable  to  dilate  a  stricture  beyond  this  if 
possible. 

The  urethra  should  be  syringed  before  and  after  the  passage 
of  the  bougie  with  a  weak  solution  of  permanganate  of  zinc  (1  in 
5,000)  or  of  silver  nitrate  (1  in  10,000). 

During  the  dilatation,  and  especially  during  the  earlier  part  of 
the  treatment,  urinary  antiseptics  should  be  administered.  Uro- 
tropine  5  gr.  thrice  daily,  hetralin  7  gr.,  helmitol  7  gr.,  and  boric 
acid  10  gr.,  are  among  the  best  of  these. 

When  the  intervals  between  the  passage  of  instruments  are 
prolonged  to  a  month,  the  patient  may  take  these  medicines  for 
two  days  before  and  two  days  after  the  operation. 

A  slight  gleet  often  accompanies  stricture,  and  should  be 
treated  by  the  patient  using  an  injection  night  and  morning  with 
a  hand-syringe.  Permanganate  of  zinc,  ^  gr.  to  the  ounce,  or 
sulphocarbolate  of  zinc  in  the  strength  of  1  per  cent.,  is  a 
suitable  injection. 

The  dilatation  of  the  stricture  will  remove  the  principal  cause 
of  the  discharge.  The  time  taken  for  the  treatment  varies  accord- 
ing to  the  behaviour  of  the  stricture.  At  the  end  of  three  months 
the  patient  may  be  in  the  position  that  a  large  steel  bougie  is 
passed  once  in  two  months.  It  is  seldom  that  a  case  can  be  dis- 
missed before  the  end  of  six  months  or  a  year.  More  often  the 
treatment    extends    over   eighteen    months    or   two    years.     Some 


xLix]  DILATATION   OF   STRICTURE  635 

patients,  especially  those  belonging  to  the  hospital  class,  are  care- 
less and  irregular  in  their  attendance,  and  after  a  time  the  stric- 
ture gets  into  a  callous  condition  which  is  beyond  the  hope  of 
complete  cure. 

Strictures  which  have  not  become  tough  and  leathery  from 
long  duration,  irregular  treatment,  and  prolonged  irritation  from 
chronic  inflammation,  will  be  cured  by  this  means.  A  few  of 
these  relapse  after  a  year  or  two,  and  require  an  instrument  at 
long  intervals. 

In  cases  in  which  the  patient  gives  a  history  of  dribbUng,  and 
the  clothes  are  saturated  and  the  prepuce  sodden  with  the  leakage, 
the  surgeon  should  at  once  resort  to  filiform  bougies,  for  the  stric- 
ture is  of  very  small  calibre.  Where  a  filiform  bougie  is  the  largest 
instrument  that  will  pass,  we  have  to  deal  with  either  a  very 
narrow  stricture,  or  a  moderate-sized  stricture  to  which  congestion 
or  spasm  is  superadded.  After  a  brisk  saline  purge  and  confine- 
ment to  bed  for  two  days,  spasm  or  congestion  will  have  sub- 
sided, a  bougie  of  moderate  size  (10  to  12  Fr.)  will  pass,  and 
intermittent  dilatation  may  be  commenced.  On  the  other  hand, 
the  stricture  may  still  grasp  a  filiform  bougie,  and  a  choice  of 
methods  is  open,  viz.  continuous  dilatation,  rapid  dilatation,  a 
cutting  operation. 

ii.  Continuous  dilatation. — Continuous  dilatation  is  useful  in 
cases  in  which  retention  of  urine  has  complicated  a  very  narrow 
stricture.  The  patient  is  confined  to  bed,  and  a  filiform  bougie 
passed  and  fastened  in  by  tying  a  silk  ligature  round  it  and 
fixing  the  ends  to  the  sides  of  the  .penis  by  means  of  plaster. 
The  urine  trickles  alongside  the  bougie  in  from  one-half  to  two 
hours.  After  twelve  hours  a  shghtly  larger  instrument  can  be 
substituted,  and  after  twenty-four  hours  a  6  or  7  Fr.  can  be  passed. 
The  continuous  dilatation  is  now  abandoned  and  intermittent 
dilatation  commenced. 

iii.  Rapid  dilatation. — This  consists  in  forcing  bougies  of  in- 
creasing size  through  the  stricture  in  rapid  succession  until  a 
large  size  is  reached.  This  may  be  carried  out  by  means  of  conical 
metal  instruments,  or,  if  only  a  filiform  bougie  can  be  passed,  a 
tunnelled  instrument  is  threaded  over  this  and  pushed  through 
the  stricture.  This  method  ruptures  the  stricture  although  the 
epithelial  covering  may  remain  intact.  At  a  later  time  a  denser 
and  more  extensive  stricture  forms.  It  is  not,  therefore,  recom- 
mended as  a  routine  method  of  treatment,  although  it  may  be 
the  only  method  available  owing  to  lack  of  instruments  or  the 
necessity  for  at  once  dilating  the  stricture  to  the  size  that  will 
admit  a  catheter. 


636  THE    URETHRA  [chap. 

It  is  not  always  possible  to  have  the  patient  in  bed  for  the 
passage  of  urethral  instruments,  nor  is  it  necessary  after  the  patient 
is  accustomed  to  the  operation,  but  it  is  essential  during  the  earlier 
operations  until  the  surgeon  is  familiar  with  the  "  temper "  of 
the  stricture  with  which  he  has  to  deal. 

Complications  of  dilatation,  {a)  False  passage.  —  Blood 
appears  at  the  meatus,  and  a  peculiar  sensation  of  fine  grating  is 
felt.  The  further  passage  of  instruments  on  the  occurrence  of 
such  an  accident  must  be  suspended.  The  urethra  should  be 
washed  with  a  warm  boric  or  permanganate-of-zinc  solution,  to 
which  a  little  hazeline  or  the  tincture  of  hamamelis  (B.P.)  may 
be  added  if  the  oozing  is  pronounced.  Copious  bleeding  rarely 
occurs.  An  ice-bag  should  be  applied  to  the  perineum.  A  week 
should  elapse  before  further  attempts  are  made  to  pass  instru- 
ments. Especial  gentleness  should  be  exercised  in  the  first  passage 
of  instruments  after  this  accident,  and  the  urethroscope  is  invalu- 
able in  demonstrating  the  position  of  the  urethral  opening  and 
the  false  passage.  Where  a  false  passage  of  old  standing  is  known 
to  be  present  it  may  be  avoided  by  passing  a  fine  bougie  gently 
into  it  and  then  introducing  a  second  into  the  urethra  alongside 
the  first  bougie. 

(6)  Infection. — This  is  prevented  by  the  sterilization  of  instru- 
ments, of  lubricant,  and  of  the  hands,  and  the  washing  of  the 
penis  and  urethra  before  the  passage  of  instruments.  Urinary 
antiseptics  are  also  valuable  in  preventing  the  occurrence  of  the 
infection  and  in  its  treatment.  An  injection  with  a  hand-syringe 
of  a  solution  of  permanganate  of  zinc,  J  gr.  to  the  ounce,  or  of 
sulphocarbolate  of  zinc,  ^  per  cent.,  or  a  copious  daily  urethral 
lavage  by  means  of  a  douche-can  and  urethral  nozzle  with  per- 
manganate of  zinc  (1-5,000),  will  quickly  cure  the  urethritis. 

If  a  rigor  occurs,  the  patient  is  confined  to  bed,  surrounded 
by  hot  bottles,  and  hot  drinks  such  as  tea  or  hot  Contrexeville 
water,  and  drugs  such  as  quinine  and  urotropine,  are  given.  A 
brisk  saline  purge  should  be  administered. 

(c)  Syncope.— A  sense  of  faintness  or  actual  syncope  may 
occur  during  the  passage  of  instruments.  For  this  reason  the 
patient  should  invariably  be  in  the  recumbent  position  during 
the  operation.  The  usual  remedies  for  syncope  are  adopted,  and 
the  instrumentation  is  suspended.  On  succeeding  instrumentations 
a  solution  of  eucaine,  8  per  cent.,  should  be  injected  into  the 
urethra  as  a  precaution  against  this  accident.  Cocaine  should 
not  be  used  as  a  routine  measure,  for,  besides  the  danger  of  ab- 
sorption of  the  drug,  the  surgeon  loses  a  very  important  guide  and 
check  to  his  manipulation  when  he  abolishes  the  urethral  sensation. 


xLix]    STRICTURE:  OPERATIVE  TREATMENT      G37 

Spasmodic  stricture. — The  spasm  aft'ects  the  constrictor 
urethJrse,  and  the  obstruction  is  in  the  membranous  urethra.  The 
obstruction  is  intermittent ;  in  an  organic  stricture  it  is  con- 
tinuous and  increasing  if  untreated. 

In  spasmodic  stricture  a  large  instrument,  if  gently  handled, 
will  pass  on  after  a  slight  delay.  The  use  of  cocaine  (10  or  15 
minims  of  a  2  per  cent,  solution)  is  permissible  and  advantageous 
if  the  diagnosis  has  been  clearly  established. 

The  cause  of  the  urethral  spasm  must  be  dihgently  sought, 
for  upon  it  depends  the  treatment.  Causes  of  reflex  irritation, 
such  as  anal  fissure,  inflamed  piles,  etc.,  should  be  treated,  when 
present.  Most  frequently  the  spasm  results  from  some  urethral 
irritation,  such  as  subacute  inflammation  in  the  prostatic  urethra, 
or  a  small  stone  caught  in  this  portion  of  the  urethra  in  its  out- 
ward passage.  The  latter  accident  will  be  treated  by  passing  a 
large  steel  bougie  and  pushing  the  calculus  back  into  the  bladder, 
when  it  will  be  dealt  with  as  a  bladder  stone.  Posterior  urethritis 
is  treated  by  the  passage  of  a  large  metal  instrument  and  the 
instillation  of  a  few  drops  of  nitrate  of  silver  solution  (5  gr.  to 
the  oimce)  into  the  prostatic  urethra  by  means  of  a  Guyon's 
syringe.  Two  or  three  instillations  at  intervals  of  a  week  will 
usually  suffice.  Ketention  of  urine  as  a  complication  of  this 
condition  should  be  treated  by  a  hot  sitz-bath  and  an  opiate, 
and,  these  failing,  by  the  passage  of  a  catheter. 

2.  Operative  treatment. — While  the  majority  of  cases  of 
stricture  are  cured  or  relieved  by  the  passage  of  instruments,  in 
a  certain  number  of  cases  a  cutting  operation  becomes  necessary. 
The  indications  for  operation  are  as  follows  : — 

A.  Gradual  dilatation  may  have  jailed. 

(1)  In  cases  of  hard  cartilaginous  stricture  dilatation  may 

be  carried  up  to  a  certain  size,  and  no  further  pro- 
gress be  made. 

(2)  Resilient   stricture.     The   stricture   is   readily   dilated 

but  quickly  relapses. 

(3)  Rigors   follow   the   passage    of    an    instrument   under 

aseptic  precautions. 

(4)  Haemorrhage.     A  few  strictures  bleed  at  the  slightest 

touch  of  a  bougie,  apart  from  any  lack  of  skill  or 
want  of  care. 

(5)  Repeated  attacks  of  epididymitis. 

(6)  Recurrent  attacks  of  retention  of  urine  following  the 

passage  of  instruments  in  strictures  of  moderately 
large  calibre. 

(7)  Periurethral  abscess  and  extravasation  of  urine. 


638  THE   URETHRA  [chap. 

B.  Cases  unsuitable  for  gradual  dilatation. 

(1)  The   stricture   is  impassable   to  the  finest   bougie,   or 

only  admits  a  filiform  bougie  with  difficulty  on  several 
occasions. 

(2)  In    cases  of    urethral    stone,   periurethral  abscess,   ex- 

travasation of  urine,  and  urethral  fistula. 

(3)  The  stricture  may  be  a  complication  of  some  disease 

of  the  prostate  or  bladder,  such  as  enlargement  of 
the  prostate,  stone,  tuberculosis,  chronic  cystitis, 
new  growths. 

(4)  In  some  diseases  of  the  kidneys  complicating  stricture. 

C.  The  fotient  is  unable  or  unwilling  to  carry  out  gradual 
dilatation. 

(1)  He  may  be  going  abroad  out  of  reach  of  medical  aid. 

(2)  He  may  be  unable  to  find  time  for  gradual  dilatation. ' 
Internal    urethrotonny. — The  stricture  is  cut  by  means  of  a 

guarded  knife  (urethrotome)  introduced  along  the  urethra.  (Fig. 
193.) 

The  author's  modification  of  Maisonneuve's  urethrotome  con- 
sists of  filiform  guides  which  screw  on  to  the  end  of  a  fine  grooved 
staff,  and  a  triangular  knife  which  runs  in  the  groove.  The  modi- 
fications consist  in  (1)  making  the  metal  attachment  of  the  guide 
taper,  and  placing  it  inside  the  end  of  the  guide  instead  of  having 
an  abrupt  metal  shoulder  from  which  the  flexible  guide  tends  to 
break ;  (2)  the  groove  ends  just  beyond  the  commencement  of 
the  curve,  so  that  the  knife  does  not  enter  the  prostatic  urethra  ; 
(3)  two  wings  are  provided  to  hold  the  instrument  steady ;  (4) 
a  metal  rod  is  provided  which  fits  into  the  groove  during  intro- 
duction and  prevents  buckling  when  the  stricture  is  narrow  and 
hard.  (Fig.  194.)  This  rod  is  removed  before  the  knife  is  intro- 
duced. A  general  anaesthetic  should  be  given,  and  the  urethra 
thoroughly  washed  with  a  weak  solution  of  nitrate  of  silver,  1  in 
10,000.  The  surgeon  stands  on  the  right  side  of  the  patient,  and 
the  assistant  opposite  to  him.  The  guide  is  introduced  through 
the  stricture  and  the  staff  screwed  into  it. 

The  staff  is  now  made  to  follow  the  guide,  which  is  pushed  into 
the  bladder  and  coils  up  there.  The  staff  is  held  by  an  assistant 
at  an  angle  of  45°  with  the  horizontal.  He  grasps  the  wings  of 
the  urethrotome  with  a  thumb  on  the  upper  surface  of  each,  and 
holds  the  instrument  absolutely  steady  in  the  middle  line.  The 
triangular  knife  is  run  along  the  groove  and  passed  sharply 
through  the  stricture ;  as  it  is  being  withdrawn  resistance  is 
again  felt,  and  the  posterior  cutting  surface  of  the  knife  cuts 
the  stricture    a  second    time.      Large   metal    instruments  (12-14 


xux] 


INTERNAL  URETHROTOMY 


039 


to   14-lG)  are   now  passed  to   make  certain  that  the   stricture^  i,s 
completely  cut. 

A  coude  catheter  (-i-i  Fr.)  is  passed  and  the  bladder  washed  out 


Fig.  193. — Internal  urethrotomy. 

The  metal  guide  has  been  passed  through  the  stricture,  and  its  off  transverse  wing  is  held  by  the 

thumb  and  forefinger  of  the  assistant's  right  hand  (the  assistant's  left  hand,  which  should  hold 

the  near  transverse  wing,  is  not  shown).     The  operator  has  inserted  the  triangular  knife  in  the 

groove  of  the  guide  and  is  holding  the  penis  preparatory  to  pushing  the  knife  home. 

with  weak  nitrate  of  silver  solution,  and  the  catheter  tied  in.  A 
roll  of  gauze  is  placed  around  the  catheter  at  the  external  meatus 
and  fixed  with  adhesive  plaster.  The  catheter  is  plugged,  and  the 
urine  withdrawn  everv  two  hours. 


Fig.  194. — Author's  urethrotome. 

After  forty-eight  hours  the  catheter  is  removed,  the  urethra 
washed  with  nitrate  of  silver  solution,  and  the  patient  passes 
urine  himself. 

Internal  urethrotomy  may  be  performed  from  behind  forwards 


640  THE   URETHRA  [chap. 

by  using  a  Civiale's  urethrotome,  which  is  passed  through  the 
stricture,  the  blade  projected,  and  the  stricture  cut  as  it  is  with- 
drawn. The  stricture  must  previously  have  been  dilated  to  the 
size  of  No.  5  E. 

The  patient  is  kept  in  bed  for  a  week  and  then  allowed  up. 
No  instruments  are  passed  for  fourteen  days  after  the  operation, 
and  then  a  full-sized  metal  instrument  is  introduced.  A  fortnight 
later  instruments  are  again  passed,  and  if  the  surgeon  be  satisfied 
that  no  recontraction  is  taking  place  the  next  visit  should  be 
paid  a  month  later,  then  at  intervals  of  two,  three,  four,  and  six 
months ;  and  eventually  the  patient  returns  at  the  end  of  a  year's 
interval,  when,  if  no  obstruction  to  the  passage  of  a  large  metal 
instrument  is  detected  and  no  fibrous  ring  is  seen  with  the  aero- 
urethroscope,  he  may  be  dismissed  as  cured.  Should  recontraction 
of  the  stricture  take  place,  instruments  must  be  regularly  passed 
at  proper  intervals. 

Diffwidties  and  dangers. — i.  The  fine  guide  of  the  urethrotome 
may  break  across  at  the  metal  attachment.  This  is  a  rare  accident 
and  is  due  to  an  imperfect  instrument.  To  prevent  it,  the  metal 
portion  of  the  guide  should  be  tapered  inside  the  flexible  portion. 
A  lithotrite  should  at  once  be  passed,  and  the  guide  caught  and 
withdrawn.  Failing  this,  a  Luys'  direct  cystoscope  should  be 
passed  and  the  bougie  seized  with  fine  forceps  or  caught  with  a 
hook.  Should  this  fail,  perineal  cystotomy  should  be  performed 
and  the  instrument  removed  by  this  route,  and  a  drainage  tube 
placed  in  the  bladder. 

ii.  After  removal  of  the  urethrotome  the  surgeon  may  fail  to 
pass  a  metal  sound.  The  staff  of  the  urethrotome  with  a  small 
metal  bulbous  tip  attached  should  be  passed,  and  the  stricture 
again  cut.  If  this  fail,  a  Harrison  whip  bougie  is  the  instrument 
most  likely  to  pass.  Should  the  attempt  be  unsuccessful,  the 
patient  should  be  returned  to  bed  and  kept  on  diuretics  and 
urinary  antiseptics  for  a  week,  when  the  instruments  will  be  found 
to  pass. 

iii.  Hcemorrhage. — Serious  haemorrhage  is  rare.  If  it  occur  the 
lower  end  of  the  bed  should  be  elevated,  an  ice-bag  placed  on  the 
perineum,  and  pressure  over  this  applied  by  means  of  a  large  sand- 
bag. If  a  catheter  be  in  the  urethra,  it  should  be  allowed  to  remain 
in  situ.  A  hypodermic  injection  of  ergot  and  morphia  should  be 
given.  If  these  measures  fail,  the  catheter  should  be  removed 
and  the  urethra  irrigated  with  a  hot  solution  of  silver  nitrate, 
1  in  10,000,  or  a  solution  containing  tincture  of  hamamelis  or 
adrenalin,  and  pressure  reapplied.  If  spasm  of  the  urethra  appear 
to  be  a  factor,  hot  fomentations  may  be  tried.     Finally,  external 


xLixJ    INTERNAL  URETHROTOMY:  RESULTS    641 

urethrotomy  should  be  performed  and  a  large  rigid  tube  intro- 
duced into  the  bladder  and  packed  around  with  gauze. 

iv.  Urethral  fever. — When  no  catheter  has  been  tied  in  there 
is  frequently  a  slight  rigor  and  a  rise  of  temperature  some  hours 
after  the  operation,  following  the  first  passage  of  urine.  (Chart  17, 
p.  567.)  This  varies  in  intensity  and  duration.  It  may  be  pre- 
vented by  tying  a  catheter  in  the  urethra  at  the  operation,  and 
washing  the  bladder  and  urethra  with  nitrate  of  silver  solution. 
Rarely  a  rise  of  temperature  follows  the  removal  of  the  catheter 
thirty-six  or  forty-eight  hours  after  the  operation.  The  urethra 
should  be  washed  with  nitrate  of  silver  solution  and  the  catheter 
replaced  for  another  twenty-four  hours. 

V.  Anuria. — This  is  a  rare  but  very  fatal  complication.  In 
from  six  to  twenty-four  hours  after  the  operation  there  is  a  severe 
rigor,  and  the  temperature  rises  to  104°  F.  or  higher.  The  patient 
is  restless,  the  face  dusky,  and  the  skin  clammy.  The  breathing 
is  rapid  and  later  becomes  stertorous;  muttering  delirium  and 
eventually  coma  supervene,  and  the  patient  dies  within  eighteen 
to  thirty-six  hours  of  the  rigor.  A  very  small  quantity  of  blood- 
stained urine,  or  none  at  all,  is  secreted  after  the  operation. 
Prophylactic  treatment  consists  in  asepsis  and-  preparatory  wash- 
ing of  the  urethra  with  silver  nitrate  solution  and  in  tying-in 
a  catheter  after  the  operation.  When  the  condition  develops, 
venous  and  rectal  infusion  of  several  pints  of  saline  solution 
should  be  given.  In  one  case  I  performed  nephrotomy  and 
decortication  of  the  kidneys,  but  without  restoring  the  renal 
function. 

Results  of  infernal  urethrotomy. — In  most  cases  when  death 
has  followed  the  operation  it  has  resulted  from  an  exacerbation 
of  pre-existing  disease,  and  not  from  any  new  factor  introduced 
by  the  operation  itseK.  During  thirteen  years  (1895-1908)  1,018 
patients  suffering  from  stricture  were  treated  by  internal  urethro- 
tomy at  St.  Peter's  Hospital,  and  8  patients  died,  a  mortality  of 
0-78  per  cent.  Watson  and  Cimningham  united  several  series 
of  cases  recorded  in  the  hterature,  and  found  53  deaths  in  4,686 
cases,  a  mortality  of  1-1  per  cent. 

The  causes  of  death  are  exacerbation  of  old-standing  pyelo- 
nephritis (50  per  cent.),  anuria  and  uraemia,  septicaemia  and 
haemorrhage. 

After-results. — (1)  Complete  cure  may  be  obtained  without 
further  interference  in  a  small  number  of  cases.  In  the  majority 
of  cases  complete  cure  can  be  obtained  by  internal  urethrotomy 
followed  by  the  passage  of  instruments  at  long  intervals. 

(2)   Recontraction  of   the    stricture    may    occur   after  several 
2p 


642 


THE  URETHRA 


[chap. 


months  or  some  years,  but  the  occasional  passage  of  a  large  metal 
instrument  suffices  to  prevent  this. 

(3)  The  stricture  rapidly  recontracts,  and  a  cutting  operation 


Fig.   195. — Wheelhouse's  operation. 

The  urethra  opened  in  perineum,  the  lumen  of  the  stricture  is  being  sought  for. 


xLix]  EXTE:RNAL   urethrotomy  643 

must  be  repeated  and  dilatation  by  instruments  resumed.  Irregular 
attendance,  alcoholic  indulgence,  exposure,  and  individual  idio- 
syncrasy account  for  these  relapses. 

(4)  In  cartilaginous  stricture  operation  permits  the  passage  of 
large  instruments,  and  this  must  be  maintained.  In  spite  of  this 
the  stricture  may  recontract. 

External  urethrotomy. — A  variety  of  operations  may  be  per- 
formed, depending  upon  whether  it  is  possible  to  pass  an  instru- 
ment through  the  stricture  or  not. 

External  urethrotomy  with  a  guide  {Syme's  operation). — The 
stricture  is  dilated  to  a  No.  4  E.  gauge  by  means  of  bougies,  and 
a  Syme's  staff  introduced.  The  patient  is  placed  in  the  lithotomy 
position  and  an  incision  made  on  the  staff  just  behind  the  shoulder. 
The  stricture  is  cut  in  the  middle  line  and  the  incision  carried 
back  to  the  membranous  urethra,  the  probe-point  of  a  gorget  is 
introduced  into  the  groove  of  the  staff  and  pushed  into  the  bladder. 
The  staff  is  mthdrawn  and  a  perineal  drainage  tube  introduced 


^ 


Scale  3 
Fig.  196, — Wheelhouse  staff. 

and  tied  in  position,  or  a  catheter  passed  along  the  penile  urethra 
and  on  into  the  bladder. 

The  perineal  wound  is  either  left  open  or  brought  together 
with  a  few  stitches. 

External  urethrotomy  without  a  guide,  (a)  Whedhouse's  operation 
(Fig.  195). — This  and  the  following  operations  are  midertaken  when 
the  surgeon  has  failed  to  pass  an  instrument  through  the  strictm-e. 
A  Wheelhouse  staff  (Fig.  196)  is  passed  down  to  the  face  of  the 
stricture,  and  an  incision  made  upon  it  about  an  inch  from  the 
end.  The  staff  is  hooked  in  the  upper  angle  of  the  wound  and 
the  mucous  membrane  picked  up  on  each  side,  and  a  careful 
search  made  for  the  opening  ;  when  this  is  found  a  probe  is  passed 
through  the  stricture,  which  is  then  slit  up,  and  the  operation  is 
finished  as  in  Syme's  method. 

This  operation  should  not  be  performed  at  the  end  of  a  pro- 
longed and  unsuccessful  attempt  to  pass  instruments  through  a 
stricture.  In  such  a  case  some  bleeding  is  almost  invariably 
going  on,  and  obscures  the  field  in  which  search  is  to  be  made 
for  the  opening  of  the  stricture.  Unless  the  case  is  very  urgent 
the  patient  should  be  returned  to  bed  and  the  Wheelhouse  opera- 
tion performed  in  a  few  days. 


644  THE   URETHRA  [chap. 

If  Wheelhouse's  operation  fail,  one  of  the  following  procedures 
may  be  adopted : — 

(6)  The  incision  is  carried  back  and  exposes  the  dilated  urethra 
behind  the  stricture,  or  a  second  median  incision  may  be  made 
for  this  purpose  when  the  first  incision  has  been  far  forwards,  or 
a  curved  prerectal  incision  may  be  made  and  the  urethra  exposed 
by  dissection.  A  probe  is  then  passed  penis-wards  through  the 
stricture,  and  the  scar  tissue  sUt  up  upon  this. 

(c)  Cock's  operation,  which  was  originally  introduced  for  cases 
of  acute  retention  in  impassable  stricture,  may  be  done.  The 
operation  depends  upon  the  presence  of  distension  of  the  bladder 
and  dilatation  of  the  urethra  behind  the  stricture.  The  tip  of 
the  forefinger  of  the  left  hand  is  placed  in  the  rectum  on  the  apex 
of  the  prostate,  and  a  knife  entered  in  the  middle  line  of  the 
perineum  J  in.  in  front  of  the  anus  and  pushed  straight  for  this 
point.     The  dilated  urethra  behind  the  stricture  is  opened. 

(d)  Suprapubic  cystotomy  is  performed  and  retrograde  cathe- 
terization with  a  metal  sound,  and  the  point  of  this  is  cut  down 
upon  in  the  perineum.  The  operation  has  little  to  recomimend  it 
over  the  perineal  dissection  (b). 

Dangers  of  external  urethrotomy. — The  dangers  are  : 

(1)  Hsemorrhage,  which  is  controlled  by  packing  the  wound. 

(2)  Cystitis  and  septic  pyelonephritis. 

(3)  Renal  failure  and  uraemia. 

(4)  Pelvic  cellulitis. 

Resylts.—The.  mortality  was  8  per  cent,  in  100  cases  performed 
at  St.  Peter's  Hospital.  Gregory  found  a  mortality  of  8-8  per 
cent,  in  992  cases  ;  Thompson,  6-5  per  cent,  in  219  cases  ;  Howitz, 
4-3  per  cent,  in  116  cases. 

After-results. — Only  a  small  percentage  of  cases  are  cured  by 
the  operation.  When  instruments  are  passed  regularly  after  the 
operation  the  results  are  much  better  and  correspond  to  those  of 
internal  urethrotomy. 

Excision  of  strictures. — A  single  stricture  of  moderate  dimen- 
sions may  be  resected.  Every  effort  should  be  made  to  get  rid  of 
urethral  or  vesical  infection  before  the  operation.  With  this 
object  the  urethra  is  irrigated  daily  and,  if  necessary,  cystotomy 
is  performed  a  week  or  more  before  the  operation.  In  all  cases  a 
prehminary  suprapubic  cystotomy  is  performed,  and  a  rubber  tube 
fixed  in  position.  The  patient  is  placed  in  the  lithotomy  posi- 
tion and  a  gum-elastic  bougie  passed  through  the  stricture.  A 
median  incision  2  in.  long  is  made,  with  the  stricture  as  its  centre. 
If  the  stricture  is  situated  in  the  bulbous  urethra  the  compressor 
urethrse  is  divided  along  the  middle  line.      Goldmann  and  Hey 


xLix]  EXCISION   OF  STRICTURE  645 

G-roves  have  insisted  on  the  necessity  of  excising  the  whole  thick- 
ness of  the  spongy  body  with  the  strictured  portion  of  the  urethra. 
This  does  not  interrupt  the  circulation  of  the  peripheral  end  of  the 
spongy  body,  for  the  glans  and  spongy  body  are  supplied  by  the 
dorsal  artery  of  the  penis  as  well  as  by  the  artery  to  the  bulb. 
The  strictured  portion  of  the  urethra,  together  with  the  spongy 
body  overlying  it,  having  been  removed,  the  ends  of  the  severed 
tubes  are  carefully  united  with  fine  catgut  on  the  metal  instru- 
ment. Over  this  the  fibrous  sheath  is  accurately  united  and  the 
compressor  urethra?  and  perineal  muscles  are  carefully  brought 
together.  The  instrument  is  now  removed.  The  suprapubic 
wound  is  drained  by  means  of  a  suction  apparatus  for  seven  or 
ten  days. 

The  extent  of  urethra  that  has  been  removed  by  excision  has 
varied.  Burckhardt  resected  6  cm.  (about  2J  in.),  and  Goldmann 
a  portion  measuring  8  cm.  (about  3^  in.).  The  subsequent  for- 
ward curving  of  the  penis  on  erection  gradually  disappears. 

Results. — In  18  cases  collected  by  Nogues  and  Viguard  there 
was  no  recurrence  at  the  end  of  periods  varying  from  six  months 
to  eight  years.  Similar  results  have  been  described  by  Heusner, 
Horteloup,  Rutherfurd^  and  others. 

Watson  and  Cunningham  collected  64  cases  of  resection,  but 
only  in  13  was  there  any  information  in  regard  to  the  urethra 
more  than  a  year  after  the  operation.  In  these  the  result  was 
satisfactory  from  one  year  to  six  and  a  half  years  after  the 
operation. 

Selection  of  operation.  —  The  following  points  must  be 
considered : — 

i.  Position  of  the  stricture. — A  penile  stricture  is  -unsuitable  for 
external  urethrotomy,  for  a  fistula  is  likely  to  follow.  Internal 
urethrotomy  with  subsequent  dilatation  or  resection  of  the  stricture 
is  preferable.     Stricture  of  the  bulb  is  suitable  for  any  operation. 

ii.  Character  of  the  stricture. — Soft  annular  strictures  are  espe- 
cially suitable  for  internal  urethrotomy.  A  hard  cartilaginous 
inflammatory  traumatic  stricture  may  be  cut  by  internal  or 
external  urethrotomy,  but  in  either  case  instruments  must  be 
used  afterwards.  Excision  of  the  stricture  will  be  more  likely  to 
give  a  permanently  successful  result. 

iii.  Thoroughness  of  the  operation. — Excision  is  the  most  radical 
operation.  External  urethrotomy  cuts  through  a  greater  depth, 
but  it  only  cuts  the  narrowest  stricture,  which  lies  nearest  the 
bladder,  and  neglects  the  wider,  more  peripheral  strictures.  Internal 
and  external  urethrotomy  may  be  combined  and  overcome  this 
objection. 


646  THE   URETHRA  [chap,  xlix 

iv.  Convalescence  lasts  a  week  or  ten  days  after  internal  and  two 
to  three  weeks  or  sometimes  longer  after  external  urethrotomy. 

V.  Danger. — The  mortaUty  figures  are  deceptive,  since  the  worst 
types  of  stricture  are  submitted  to  external  urethrotomy.  The 
danger  depends  rather  upon  the  complications  of  the  stricture 
than  upon  the  operation. 

vi.  AJter-residts. — Recontraction  occurs  after  both  internal  and 
external  urethrotomy  in  almost  equal  degree. 

vii.  Complications. — External  urethrotomy  becomes  necessary 
when  local  complications  such  as  periurethral  abscess,  fistula, 
extravasation  of  urine,  or  urethral  calculus  are  present. 

LITERATURE 

Albarran,  XIIP  Congres  Intemat.  de  Med.,  1900. 

Antal,  Centralbl.  f.  d.  Krankh.  d.  Ham-  u.  Sex. -Org.,  ii.  366. 

Ballinger,  Med.  Neivs,  Nov.  11,  1905. 

Berg,  Ann.  Surg.,  1903,  No.  4. 

Burckhardt,  Handbuch  der  Urologie  (von  Frisch  und  Zuckerkandl),  1906,  Bd.  iii. 

Goldberg,  Deuts.  Zeits.  f.   Chir.,  1900,  p.  393. 

Goldmann,  Beitr.  z.  klin.  Chir.,  1904,  Bd.  xlii. 

Groves,  Hey,  Bristol  Med.- Chir.   Journ.,  1910,  p.  325. 

Hagler,  Deuts.  Zeits.  j.  Chir.,  Bd.  xxix. 

Heresco,  XIIP  Congres  Internat.  de  Med.,  1900. 

Heusner,  Deuts.  med.   Woch.,  1883,  Nr.  28. 

Ingianni,  Deuts.  Zeits.  f.  Chir.,  1900,  Bd.  liv. 

Le  Fur,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1905,  i.  1. 

Lichtenstern,  XVP  Congres  Internat.  de  Med.,  Budapest,  1909,  p.  436, 

Lydston,  Med.  News,  March  4,  1899. 

Martel,  Presse  Med.,  1904,  p.  289. 

Martens,  Die  Verletzungen  und  Verengerungen  der  Harnrohre.     Berlin,  1902. 

Poussou,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1891,  p.  20. 

Rutherfurd,  Lancet,  Sept.  10,  1904. 

Sawamura,  Folia  Urol.,  1910,  Bd.  iv.,  S.  683. 

Thomas,  Brit.  Med.  Journ.,  Nov.  8,  1902. 

Walker,  Thomson,  Burghard's  System  of  Operative  Surgery,  vol.  iii.     1909. 

Wassermann  et  Halle,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1894,  p.  241. 

Watson  and  Cunningham,  Surgery  of  the  Genito-  Urinary  System,  vol.  ii.     1909. 


CHAPTER  L 
PERIURETHRITIS-URETHRAL  FISTULA 

PERIURETHRITIS  AND  PERIURETHRAL    SUPPURATION 

The  source  of  infection  is  the  urethra,  and  the  inflammation  takes 
various  forms,  such  as  abscess,  fibrous  masses,  and  gangrenous  or 
phlegmonous  inflammation,  or  extravasation  of  urine. 

Etiology. — In  the  majority  of  cases  the  urethra  is  the  seat 
of  stricture,  but  injury  from  the  passage  of  -instruments  or  internal 
urethrotomy,  new  growths  of  the  urethra,  foreign  bodies,  calculi, 
or  a  retained  metal  catheter,  may  be  the  predisposing  cause.  There 
is  usually  a  mixed  infection  of  bacillus  coli,  streptococcus,  and 
staphylococcus ;  less  frequently  the  colon  bacillus  is  found  as 
a  pure  culture,  and  ■  rarely  the  streptococcus  is  present  alone. 
Anaerobic  bacteria  have  been  fomid  most  frequently  mixed  with 
aerobic  bacteria,  but  occasionally  alone. 

The  following  varieties  were  isolated  by  Cottet,  viz.  micro- 
coccus foetidus,  bacillus  fragilis,  bacillus  funduliformis,  staphylo- 
coccus parvulus,  bacillus  nebulosus,  diplococcus  reniformis.  An- 
aerobic bacteria,  especially  the  bacillus  perpingus,  are  particularly 
frequent  in  the  phlegmonous  form  of  periurethritis — extravasation 
of  urine  (Jungano). 

When  a  stricture  is  present,  urine  collects  in  the  dilated  urethra 
behind  it,  and  the  mucous  membrane  is  inflamed.  According  to 
Legueu  and  Nogues,  the  inflammation  spreads  to  the  periurethral 
tissue  by  phlebitis  and  thrombosis  in  the  corpus  spongiosum ;  but 
Motz  and  Bartrina  support  the  more  widely  accepted  view  that 
the  inflammation  spreads  along  the  ducts  of  the  urethral  glands 
— namely,  the  glands  of  Littre,  Cowper's  glands,  and  also  the 
prostate. 

Periurethral  Abscess,  "  Urinary  Abscess  " 
The  abscess  may  develop  in  relation  to  the  penile  or  the  bulbous 
urethra. 

In  the  'penile  urethra  a  periurethral  abscess  occurs  most  fre- 
quently during  the  acute  stage  of  an  attack  of  gonorrhoea,  less 
frequently    in    chronic    urethritis.      It    is    often  situated   at    the 

647 


648  THE   URETHRA  [chap. 

base  of  the  glans  penis,  but  any  part  of  the  penile  urethra  may 
be  affected.  A  tender  sweUing  appears  on  the  under  surface  of 
the  penis,  the  skin  becomes  red  and  tense,  and  the  abscess  fre- 
quently bursts  externally  at  one  or  both  sides  of  the  frsenum  or 
nearer  the  scrotum,  according  to  the  position  of  the  abscess. 
Rupture  into  the  urethra  may  also  take  place.  A  urinary  fistula 
usually  follows. 

Abscess  around  the  bulbous  urethra  may  develop  in  relation  to 
the  perineal  or  scrotal  portion.  The  abscess  may  form  insidiously, 
and  cause  only  slight  pain  on  pressure  or  sitting,  and  is  felt  as  a 
firm,  tender  nodule.  The  onset  and  course  may  be  more  acute, 
and  there  are  a  rigor,  fever,  and  severe  local  pain  and  tenderness, 
and  a  hard  swelling  of  considerable  size  quickly  forms  in  the 
median  line  of  the  perineum  Over  the  bulbous  urethra.  The  skin 
is  red,  tense,  and  glazed.  As  the  swelling  increases  it  passes  for- 
wards under  cover  of  the  scrotum,  but  is  limited  posteriorly  by 
the  fascia  of  Colles,  which  dips  behind  the  transverse  perineal 
muscle  at  the  level  of  the  central  point  of  the  perineum,  and  laterally 
by  the  attachment  of  this  fascia  to  the  rami  of  the  ischium  and 
pubes. 

Partial  or  complete  retention  of  urine  is  often  present. 
The  diagnosis  of  periurethral  abscess  should  be  made — from 
anal  abscess  and  ischio-rectal  abscess,  by  the  position  ;  from  abscess 
of  Cowper's  gland,  by  the  unilateral  position  and  the  filling-up 
of  the  sulcus  at  the  side  of  the  membranous  urethra  on  rectal 
examination  in  the  latter ;  and  from  a  prostatic  abscess  burrowing 
into  the  perineum,  by  rectal  examination.  Periurethral  abscess 
rarely  forms  the  starting-point  of  phlegmonous  periurethritis. 
Rupture  into  the  urethra  may  occur,  and,  if  untreated,  rupture  on 
the  surface  may  also  take  place,  and  a  urinary  fistula  is  formed. 
Treatment. — A  fenUe  periurethral  abscess  should  be  opened 
through  the  urethra  if  it  lies  in  the  anterior  part  of  the  canal.  This 
may  be  done  with  the  aid  of  a  wire  speculum  and  reflected  light, 
or  a  short  urethral  tube  and  urethroscope,  A  fine  knife  may 
sometimes  be  passed  carefully  along  the  urethra  and  plunged  into 
the  abscess,  which  is  held  between  the  finger  and  thumb  of  the 
left  hand.  The  urethra  should  be  washed  daily  with  mild  anti- 
septic solutions. 

In  'perineal  periurethral  abscess  all  intra -urethral  treatment 
should  be  stopped  and  hot  fomentations  applied,  and  the  abscess 
opened  by  a  free  median  perineal  incision  as  soon  as  possible.  The 
cavity  is  flushed  with  a  large  quantity  of  biniodide  solution  (1  in 
5,000)  and  all  pockets  are  freely  opened,  counter-openings  being 
made  if  necessary.     One  or  more  drainage  tubes  are  inserted,  and 


L]  EXTRAVASATION   OF   URINE  649 

the  cavity  is  lightly  packed  with  iodoform  gauze,  which  is  re- 
newed daily.  The  cavity  granulates,  and  the  convalescence  vdW 
take  about  five  or  six  weeks. 

It  is  seldom  necessary  to  treat  the  stricture  at  the  same  time. 
Internal  urethrotomy  should  be  performed  when  the  perineal 
wound  is  nearly  healed.  When  a  narrow  stricture  and  severe 
cystitis  coexist  the  perineal  incision  should  be  used  to  perform 
external  urethrotomy^,  and  a  large  rubber  drain  placed  in  the 
bladder. 

Diffuse  Phlegmonous  Periurethritis,  "  Extravasation 
OF  Urine  " 

This  is  a  virulent,  rapidly  spreading  cellulitis,  with  sloughing 
of  the  urethra.  It  was  at  one  time  believed  that  the  condition 
consisted  in  infiltration  by  infected  urine  which  was  forced 
through  the  urethral  wall  behind  a  stricture,  but  this  view  is  now 
abandoned.  Stricture  is  usually  present,  but  may  not  be  narrow, 
and  cases  occur  in  which  no  stricture  has  existed. 

The  bacteriology  has  already  been  described ;  anaerobic  bacteria 
are  specially  common  in  this  disease.  The  condition  may  com- 
mence in  a  periurethral  abscess,  but  more  commonly  the  onset  is 
sudden,  and  the  symptoms  at  once  become  severe. 

After  a  rigor  the  temperature  rises  to  102°  F.  or  higher,  and 
profound  toxeemia  rapidly  develops.  The  patient  is  pale  and  the 
skin  clammy,  the  tongue  and  mouth  become  dry  and  coated, 
and  delirium  appears.  The  urine  is  passed  with  difficulty  and 
in  small  quantity.  A  dull-red  brawny  induration  appears  in  the 
perineum,  and  rapidly  increases.  The  spread  is  limited  by  the 
attachments  of  Colles's  fascia  to  the  triangular  ligament  behind 
the  transverse  perineal  muscle  posteriorly,  and  laterally  to  the 
rami  of  the  ischium  and  pubes.  The  scrotum  becomes  oedematous 
and  red,  the  penis  swollen  and  distorted,  and  the  infiltration  rapidly 
mounts  on  to  the  pubes  and  abdominal  wall.  Crepitation  from 
the  formation  of  gas  may  sometimes  be  detected.  A  fatal  result 
from  toxsemia  is  not  uncommon,  and  may  occur  after  operation. 

Treatment. — Operation  should  be  performed  at  the  earliest 
moment.  Multiple  incisions  are  made  in  the  skin  of  the  scrotum, 
perineum,  and  abdominal  wall,  wherever  the  infection  has  spread. 
A  constant  stream  of  hot  biniodide  of  mercury  solution,  1  in  2,000, 
plays  upon  the  parts,  and  is  made  to  flow  from  one  opening  to 
another ;  or  peroxide  of  hydrogen  may  be  used.  The  skin  of  the 
scrotum  is  grasped  and  the  thin  sanious  fluid  expressed.  It  is 
not  necessary  to  insert  drainage  tubes,  as  the  multiple  incisions 
should  lay  the  sloughing  tissues  freely  open.      Hot  fomentations 


650  THE   URETHRA  [chap. 

are  applied  and  frequently  changed,  and  the  wounds  are  irrigated 
several  times  in  the  twenty-four  hours  with  peroxide  of  hydrogen. 
Stimulants  should  be  freely  administered,  and  subcutaneous  or 
rectal  saline  infusions  given.  It  is  not  advisable  to  place  a  drainage 
tube  in  the  bladder,  as  this  may  result  in  a  violent  cystitis  where 
only  a  mild  infection  of  the  bladder  was  previously  present.  Slough- 
ing of  portions  of  the  bulbous  urethra  takes  place,  and  urine  is 
discharged  from  one  or  more  of  the  perineal  incisions.  The  con- 
valescence is  usually  prolonged.  As  soon  as  the  condition  of  the 
patient  will  permit  he  should  be  placed  in  a  sitz-bath  to  which 
permanganate  of  potash  or  solution  of  iodine  is  added,  and  should 
sit  in  it  for  one-half  to  one  hour  at  a  time  several  times  daily.  At 
a  later  date  treatment  for  stricture  and  fistula  may  be  required. 

Chronic  Indurative  Periurethritis 

This  condition  affects  the  bulbous  urethra,  and  large  masses 
of  fibrous  induration  form  in  the  perineum  and  scrotum.  There 
is  a  stricture  of  the  urethra,  which  is  usually  of  the  irregular  carti- 
laginous type.  The  onset  may  be  gradual,  but  there  is  usually  a 
periurethral  abscess  which  has  ruptured  on  the  surface,  besides 
several  urinary  fistulee.  Around  these,  thick  masses  of  fibrous 
tissue  gradually  form.  In  the  indurated  mass  there  is  frequently 
one,  and  sometimes  there  are  several  small  abscesses.  Several 
fistulse  may  open  into  a  common  cavity,  and  this  again  into 
the  bulbous  urethra. 

Calculi  may  form  in  the  fistulee  or  in  the  urethra  behind  the 
stricture,  and  a  malignant  growth  has  been  known  to  develop. 

Symptoms. — There  is  usually  a  long  history  of  symptoms 
of  stricture,  and  operations  may  have  been  performed  for  its  relief! 
A  perineal  abscess  has  formed  and  ruptured  or  been  incised,  and 
then  the  urethra  has  been  neglected.  Urine  escapes  from  one  or 
several  fistulse  during  micturition,  and  the  perineum  may  resemble 
the  rose  of  a  watering-can :  micturition  must  be  performed  in  the 
squatting  posture.  The  fistulse  make  tortuous  tracks,  and  fre- 
quently intercommunicate.  The  induration  forms  a  large,  irregular 
hard  mass  in  the  perineum  and  scrotum.  An  impassable  cartila- 
ginous stricture  is  frequently  present. 

Treatment. — If  a  filiform  bougie  can  be  passed,  internal 
urethrotomy  should  be  performed  as  a  preliminary  to  operation 
on  the  periurethral  induration  a  week  or  more  later.  If  the  stric- 
ture be  impassable,  external  urethrotomy  is  performed  at  the  time 
of  the  perineal  operation. 

When  a  large  mass  of  infiltration  exists  and  internal  urethrotomy 
has  previously  been  performed,  a  staff  is  placed  in  the  urethra,  the 


l]  fistula   of  urethra  651 

patient  placed  in  the  lithotomy  position,  and  the  indurated  mass 
split  down  to  the  corpus  spongiosum  in  the  middle  line.  The  mass 
is  seized  on  one  side  by  forceps  and  removed,  healthy  tissue  being 
cut  through  at  the  edge  of  the  induration,  and  then  the  second 
half  is  treated  in  the  same  manner,  all  the  fistulee  in  the  mass 
being  included.  If  fistulse  or  pockets  remain,  these  are  freely 
opened  up  and  scraped,  and  indurated  tissue  around  them  is 
removed. 

The  opening  into  the  urethra  is  found  and  repaired  with  catgut 
sutures.  A  large  raw  surface  remains  after  the  excision.  This  is 
reduced  as  far  as  possible  by  suturing  from  before  backwards,  and 
the  remainder  left  open  to  granulate.  A  catheter  is  tied  in  the 
urethra.  When  the  stricture  is  impermeable  external  urethrotomy 
is  performed  at  the  end  of  the  operation.  There  is  usually  little 
difficulty  in  exposing  and  opening  the  dilated  portion  of  the  urethra 
behind  the  stricture. 

LITERATURE 

Albarran  et  Cottet,  Presse  Med.,  1903,  p.  85. 

Escat,  Ann.  d.  Mai.  d.   Org.   Gen.-  Urin.,  1904,  p.   1761. 

Legueu  et  Nogues,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1903,  p.  822. 

Motz  et  Batrina,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1903,  p.  1601. 

Walker,  Thomson,  Burghard's  System  of  Operative  Surgery,  vol.  iii.     1909. 

FISTULA  AND   OTHER  DEFECTS  OF   THE  URETHRA 

Urethral  fistula  may  be  congenital  or  acquired,  and  may  open 
on  the  skin  of  the  penis,  scrotum,  perineum,  groin,  or  gluteal 
region,  or  into  the  rectum.  There  may  either  be  a  fistulous  track, 
which  may  be  tortuous  and  branching,  or  the  opening  may  be 
direct. 

Etiology. — Congenital  fistula  may  take  the  form  of  hypo- 
spadias or  epispadias  (p.  573). 

The  most  common  congenital  form  is  a  fistula  of  the  deep  urethra, 
and  is  combined  with  atresia  ani.  The  fistula  may  open  into  either 
the  membranous  or  the  prostatic  urethra.  In  a  man  on  whom  I 
operated  there  had  been  atresia  of  the  anus  at  birth,  and  the 
rectum  had  been  incised.  There  was  a  recto-urethral  fistula  which 
admitted  the  forefinger  and  opened  into  the  membranous  urethra. 
A  large  round  calculus  occupied  this  portion  of  the  canal,  and  in 
front  of  it  were  two  congenital  strictures,  between  which  lay  another 
calculus.  The  perineal  muscles  were  atrophied,  and  the  recto- 
urethral  septum  was  as  thin  as  paper. 

Acquired  fistula  is  due  to  trauma,  inflammation,  or  new  growth. 
Traumatic  fistula  arises  from  within  the  urethra  from  false  passages 
and  sloughing  due  to  tying-in  a  metal  catheter,  from'^without  by 


652 


THE  URETHRA 


[chap. 


stabs,  impalement,  bullet  womids,  etc.,  or  after  surgical  operations 
such  as  external  urethrotomy,  perineal  prostatectomy,  opening 
(or  rupture)  of  a  periurethral  abscess,  or  the  incision  of  gangrenous 
periurethritis.  Tuberculosis  and  bilharziosis  are  rare  causes  of 
fistula. 

Symptoms.- — Urine  escapes  from  the  fistula  during  micturition. 
The  symptoms  of  stricture  are  also  present  when  the  urethra  is 
narrowed.  The  quantity  of  urine  which  escapes  varies  from  a 
few  drops  to  half  or  more  of  the  total  quantity  passed. 

Fistula  of  the  'penile  urethra  opens  directly  into  the  urethra, 
and  is  surrounded  by  a  firm  ring  of  fibrous  tissue.     A  fistula  opening 

at  the  side  of  the 
frsenum  may  have  an 
oblique  track. 

In  'perineal  fistula 
there  may  be  one  or 
several  openings.  A 
single  fistula  is  sur- 
rounded by  a  tube  of 
hard,  fibrous  tissue ; 
where  a  number  of 
fistulse  are  present 
there  is  usually  a  large 
indurated  mass  in  the 
scrotum  or  perineum. 
A  probe  shows  that 
the  fistula  is  tortuous, 
and  occasionally  a 
stone  can  be  felt  in 
the  fistula  or  in  the 
urethra.  In  a  small, 
old-standing  fistula  the 
opening  may  be  difficult  to  discover,  being  hidden  in  a  depressed 
and  irregular  scar.  The  skin  is  often  inflamed  and  excoriated 
by  soiling  with  urine. 

In  urethro-rectal  fistula  the  urine  is  discharged  into  the  rectum 
at  each  micturition,  and  this  produces  a  watery  motion,  with  or 
without  fsecal  masses.  Gas  may  be  passed  along  the  urethra,  and 
fsecal  matter  escapes  with  the  urine.  Urethritis  and  cystitis  are 
usually  present  from  infection.  It  is  important,  in  view  of  treat- 
ment, to  ascertain  the  presence  or  absence  of  stricture,  cystitis, 
urethral  calculus,  and  the  number  and  duration  of  the  fistulous 
tracks. 

Defects  of  the  urethra  may  follow  surgical  operations  for  the 


Fig.  197. — Artificial  hypospadias  due  to 
removal  of  calculi  from  the  fossa  navi- 
cularis  and  penile  urethra. 


L] 


DEFECTS   OF  URETHRA 


653 


removal  of  calculus  from  the  urethra.  (Fig.  197.)  The  defect  may 
resemble  glandular  hypospadias  or  penile  hypospadias,  or  there 
may  be  extensive  defects  of  the  bulbous  urethra.  (Fig.  198.)  The 
rite  of  subincision  or  ariltha  (Sturt's  rite),  which  is  practised  by 
the  aboriginal  tribes  occupying  a  large  part  of  South  and  West 
Australia,  consists  in  subincision  of  the  penis,  by  means  of  a  sharp 
chipped  piece  of  flint,  so  that  the  penile  urethra  is  laid  open  from 
the  meatus  right  back  to  the  junction  with  the  scrotum.  (Fig. 
199.)  No  serious  results  follow.  In  regard  to  the  object  of  this 
rite,  Spencer  and  Gillen  state  that  "  at  the  present  day,  and  as 
far  back  as  tradition  goes, 
the  natives  have  no  idea 
of  its  having  been  insti- 
tuted with  the  idea  of  pre- 
venting or  even  checking 
procreation,"  which  it  does 
not  do.  Every  man,  with- 
out exception,  is  subincised, 
and  although  the  number 
of  children  in  a  family 
rarely  exceeds  four  or  five, 
the  reason  for  this  is  not 
subincision  but  infanticide. 
Treatment.  —  The 
treatment  of  fistula  with 
massive  induration  has  al- 
ready been  described  (p. 
650).  In  cases  without  in- 
duration less  radical  mea- 
sures may  first  be  adopted. 
If  stricture  is  present  this 
is  dilated,  or  internal  ure- 
throtomy performed,  and  a 

catheter  fixed  in  the  urethra  for  a  week  or  more.  The  fistula  is 
scraped  and  cauterized  with  the  electro-cautery  or  with  a  fine  bead 
of  silver  nitrate.  If  these  measures  are  unsuccessful  the  fistula 
should  be  excised.  In  perineal  and  scrotal  fistulse  a  metal  instru- 
ment is  passed,  and  the  patient  is  placed  in  the  lithotomy  position. 
The  fistulous  track  is  carefully  dissected  down  to  the  urethra,  the 
opening  in  the  canal  carefully  sutured  with  catgut,  and  the  wound 
closed.  A  flexible  catheter  is  substituted  for  the  metal  instru- 
ment, and  fixed  in  place  for  a  week.  Should  the  fistula  again  open, 
the  bladder  should  be  drained  suprapubically  during  the  first  ten 
days  after  the  second  operation  undertaken  to  repair  the  fistula ; 


Fig.  198.— Defect  of  floor  of  bul- 
bous urethra  following  removal 
of  calculi  of  the  bulbous  and 
prostatic  urethra. 


654 


THE  URETHRA 


[chap. 


and,  if  the  fistulae  are  numerous  and  the  operation  difficult,  it 
is  better  to  provide  suprapubic  drainage  at  the  first  operation. 
Fistulse  which  open  directly  into  the  urethra  result  from  a  loss  of 
substance  of  the  floor  of  the  urethra.  They  are  most  frequently 
observed  in  the  penile  urethra,  but  are  also  found  in  the  perineum, 
sometimes  with  extensive  defects  (2  in.  or  more)  of  the  floor  of 
the  urethra.     (Fig.  198.) 

The  bladder  should  be  drained  suprapubically  as  a  preliminary 
to  any  of  the  following  plastic  operations  on  the  urethra  : — 

Fistula  at  the  base 
of  the  glans  penis. 
DieffenbacKs  operation. 
— The  edges  of  the 
fistula  are  excised  by 
a  transverse  elliptical 
incision  and  the  raw 
edges  united  with  fine 
catgut.  A  flap  is  raised 
from  the  under  surface 
of  the  penis  with  its 
base  at  the  fistula,  and 
turned  forwards  over 
the  fistula  and  stitched 
to  a  previously  pre- 
pared raw  surface  on 
the  under  surface  of 
the  glans. 

Fistula  on  the 
under  surface  of  the 
body  of  the  penis. — 
The  edges  of  the  fistula 
are  excised  and  the 
urethra  is  closed  with 
catgut  sutures.  This 
is  covered  by  suturing  the  skin  longitudinally,  if  necessary,  making 
longitudinal  incisions  parallel  with  the  wound  to  relieve  tension ; 
or  a  quadrilateral  flap  of  skin  with  its  base  towards  the  scrotum 
may  be  raised  and  drawn  forwards  (Loumeau) ;  or  a  flap  with 
its  base  towards  the  fistula  turned  forwards,  and  this  again 
covered  by  lateral  flaps  (Guy on). 

Repair  of  acquired  urethral  defects.  1.  Autoplastic 
methods. — The  cases  suitable  for  these  methods  are  those  in  which 
the  roof  of  the  urethra  remains  intact.  The  defect  may  be  re- 
paired by  undercutting  and  sliding.     A  large  bougie  is  introduced 


Fig.  199.- — Artificial  penile  hypospadias 
(subincision)  in  aboriginal  native  of 
Australia. 


L]  REPAIR   OF   URETHRAL   DEFECTS  655 

along  the  urethra  and  lies  in  the  open  gutter  of  the  defect.  The 
urethra  is  dissected  free  on  its  under  and  lateral  surfaces  at  each 
end  of  the  defect,  an  incision  is  carried  through  the  skin  on  each 
side  parallel  to  the  gutter,  and  two  long  flaps  are  turned  over  the 
bougie  and  united.  On  each  side  a  longitudinal  flap  is  raised  by 
extensive  undercutting,  and  these  are  united  over  the  urethra. 

2.  Heteroplastic  methods. — These  are  suitable  for  cases  where 
portions  of  the  urethra  have  been  completely  destroyed  or  removed. 

Portions  of  tissue  from  other  parts  of  the  patient's  body  have 
been  used,  such  as  the  foreskin,  mucous  membrane  from  the 
lower  lip,  the  long  saphenous  vein.  Mucous  membrane  has  also 
been  transplanted  from  other  human  beings,  such  as  the  mucous 
membrane  of  a  prolapsed  uterus,  and  from  animals  (bullocks, 
goats)  and  birds. 

Operations  similar  to  those  used  after  excision  of  strictures 
may  also  be  employed. 

Results. — The  results  of  these  plastic  operations  have  not 
been  uniform.  Successes  have  been  recorded  with  all  the  methods, 
but  on  the  whole  the  autoplastic  have  been  more  satisfactory  than 
the  heteroplastic  operations. 

Urethro-rectal  fistula. — Congenital  stricture,  calcuU,  and 
other  complications  should  be  treated  before  closure  of  the  fistula 
is  attempted.  The  bladder  is  drained  by  suprapubic  cystotomy, 
and  the  bowels  are  very  thoroughly  emptied.  A  curved  pre- 
rectal  incision  is  made,  and  the  rectum  and  membranous  urethra 
are  dissected  apart,  the  fistula  being  isolated  on  all  sides  and  then 
cut  across.  The  edges  of  the  rectal  opening  are  then  united, 
and  also  those  of  the  urethral  opening. 

Ziembieckl  and  Fuller  isolate  the  extraperitoneal  portion  of 
the  rectum  and  twist  it  round  so  that  the  urethral  and  rectal 
openings  of  the  fistula  are  no  longer  opposite  each  other. 

LITERATURE 

Dittel,  Wien.  Bin.  Woch.,  1895,  No.  20. 

von  Frisch,  Internal,  klin.  Runds.,  1891,  Nos.  26,  27. 

Fuller,  Journ.  of  Cutan.  and  Gen.-  Urin.  Dis.,  April,  1897,  p.  166. 

Hallopeau,  These  de  Paris,  1906. 

Keyes,  Joum.  of  Cutan.  and  Gen.-  Urin.  Dis.,  1892,  p.  401. 

Lapiejko,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1894,  p.  41. 

Le  Prevost,  Bidl.  et  Mem.  Soc.  de  Chir.,  Paris,  1890. 

Mensel,  Be'rl.  klin.   Woch.,  1888. 

Pasteau  et  Iselin,  A?in.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1906,  ii.  1697. 

Pringle,  Ann.  Surg.,  Sept.,  1904. 

Spencer  and  Gillen,  Tk.^  Native  Tribes  of  Central  Australia. 

Wolfler,  Arch.  /.  klin.  Chir.,  1888. 

Ziembieckl,  Sem.  Med.,  1889,  p.  379. 


CHAPTER  LI 
GROWTHS  OF  THE  URETHRA 

Growths  of  the  urethra  are  comparatively  rare  ;  the  male  urethra 
is  more  frequently  affected  than  the  female.  The  benign  growths 
met  with  are  papilloma,  fibroma,  caruncle,  myoma,  adenoma, 
and  cysts ;    the  mahgnant,  carcinoma  and  sarcoma. 

Gronorrhcea  is  said  to  play  an  important  part  in  the  etiology 
of  benign  growths  of  the  urethra. 

In  the  male  the  most  frequent  forms  of  tumour  are  papilloma 
and  adenoma ;  and  in  the  female,  caruncle. 

PAPILLOMA 

Papilloma  is  found  in  the  anterior  urethra,  especially  in  the 
region  of  the  peno-scrotal  junction,  rarely  in  the  prostatic  urethra. 

In  structure  (Fig.  200)  the  growth  resembles  those  found  on 
the  glans  penis  and  foreskin.  There  is  a  central  blood-vessel 
surrounded  by  a  very  fine  layer  of  areolar  tissue,  which  in  parts, 
and  especially  in  the  finer  branches,  is  wanting,  so  that  the  epithe- 
lium is  set  directly  upon  the  wall  of  the  capillary  vessel.  The  peri- 
vascular cells  are  regular  and  vertically  arranged,  and  radiate  from 
the  vessel.  The  epithelium  is  thick,  and  towards  the  surface  the 
cells  become  large  and  more  flattened,  and  lie  parallel  with  the 
surface.  On  the  surface  is  a  layer  of  flat  cells.  A  few  branches 
pass  out  laterally,  but  the  complicated  system  of  branching  seen 
in  vesical  papilloma  is  wanting.  There  is  a  purulent  discharge, 
and  sometimes  a  peculiar  sensation  during  micturition. 

The  symptoms  are  not  distinctive,  and  the  papillomas  are 
usually  found  on  examining  a  Case  of  chronic  gleet  with  the  urethro- 
scope, (Plate  41,  Fig.  1.)  The  growths  bleed  very  readily,  and  are 
easily  torn  by  the  passage  of  instruments. 

There  may  be  a  few  isolated  growths,  or  the  urethra  may  be 
choked  with  papillomatous  masses.  Preputial  warts  are  not 
present  in  these  cases. 

Oberlander  states  that  these  warts  may  disappear  if  the  gleet 
is  cured.  This  is  exceptional,  however,  and  they  are  known  to 
persist  for  many  years.     In  a  case  observed  by  Oberlander  the 

656 


CHAP.   Ll] 


URETHRAL  PAPILLOMA 


657 


papillomas  spread  to   the   bladder   and    ultimately   became   ma- 
lignant. 

Treatment. — The  warts  should  be  removed  by  means  of  the 
urethroscope.  Ebermann  has  used  a  special  urethroscopic  tube 
with  a  lateral  eye  for  the  purpose.  A  wart  is  manoeuvred  into 
the  eye,  and  then  shorn  ofE  by  means  of  a  second,  sharp-edged 


•Jj^-J  ..  .-...-.^  7  A;-  v.-  ,•  •.  -  v- 


^i:^f  ■■'■■-■      . ;,  ''}i^>^^W-' 


«-*S- 


^^^C: ;:  - ; 


■^f^-: 


Fig.  200. — Section  of  papilloma  of  urethra. 

tube  passed  along  the  first.  Urethral  forceps  may  be  used.  The 
base  should  be  touched  with  a  4  per  cent,  nitrate  of  silver  solution. 
Several  sittings  may  be  necessary.  Recurrence  after  removal  is 
not  uncommon. 

POLYPI 

Urethral  polypi   are   usually  found  in   the   prostatic  urethra 
springing   from  the  verumontanum  or  close   to   it,  rarely  in  the 
anterior  urethra.     They  occur  usually  in  3'omig  men  or  adults. 
2q 


658 


THE   URETHRA 


[chap. 


There  are  two  forms — (1)  fibroma,  consisting  of  loose  fibrous  tissue 
with  numerous  vessels,  and  covered  with  a  thin  layer  of  mucous 
membrane  ;  (2)  adenoma,  in  which  there  are  numerous  gland  fol- 
licles. (Fig.  201.)  Most  of  the  follicles  are  dilated  and  may  contain 
intrafollicular  projections,  and  they  are  lined  with  columnar  cells 
and  set  in  a  stroma  of  loose  fibrous  tissue  and  non-striped  muscle. 
These  appearances  are  identical  with  those  of  the  "  hypertrophied  " 
prostate  gland.  They  occur  as  small  tumours  with  a  short  pedicle. 
In  a  case  of  enlarged  prostate  I  have  seen  a  bunch  of  small  adenomas 
resembling  a  papilloma,  set  on  the  end  of  a  pedicle  2J  in.  long. 


-4v»-'r\r 


^^JCvO*^.? 


Fig.  201.- — Section  of  glandular  polypus  of  prostatic  urethra. 

springing  from  the  posterior  wall  of  the  prostatic  urethra  and 
lying  in  the  bladder. 

The  fibromas  usually  arise  as  a  result  of  trauma,  portions  of 
the  mucous  membrane  being  torn  up  by  instruments — especially 
some  forms  of  prostatoscope  tube — and  these  become  covered 
with  mucous  membrane.  At  first  they  may  be  attached  at  both 
ends  or  are  sessile,  later  they  become  polypoid.  A  favourite  situa- 
tion is  on  the  montanal  ridge  in  front  of  the  verumontanum. 
Both  fibroma  and  adenoma  may  be  present  in  the  same  individual. 
Myoma  and  fibro-myoma  have  also  been  observed. 

Labhardt  collected  30  cases  of  benign  tumours  of  the  female 
urethra,  which  included  22  cases  of  fibroma,  6  of  fibro-myoma, 
and  2  of  myoma. 

Symptoms. — A  chronic  urethral  discharge  is  usually  present, 
but  there  may  be  only  a  few  shreds,  or  the  urine  may  be  clear. 
Tickling  and  crawling  sensations  in  the  urethra  are  sometimes 


LI]  URETHRAL   CARUNCLE  659 

experienced.  Haemorrhage  may  follow  the  passage  of  an  instru- 
ment. On  examination  with  the  urethroscope  the  polypus  first 
appears  as  a  round,  deep-red  or  purple  swelling  closely  surrounded 
by  the  urethral  wall.  The  pedicle  and  its  attachment  are  seen 
when  the  montanal  ridge  is  exposed  to  view.  (Plate  41,  Figs.  2,  3.) 

Treatment. — This  consists  in  removal  through  a  suitable 
urethroscope  tube  by  means  of  a  pair  of  alligator  forceps  or  a  fine 
electro-cautery.  The  operation  is  delicate,  but  presents  no  great 
diificulty. 

CYSTS 

Small  cysts  are  produced  by  blocking  of  the  outlet  of  one  of 
the  urethral  lacunae.  Cysts  of  the  sinus  pocularis  are  rare,  and 
are  usually  found  after  death.  The  contents  are  serous.  Cysts 
of  Cowper's  glands  and  ducts  result  from  blocking  of  the  ducts. 
They  may  be  found  in  children  if  a  few  days  or  months  old,  or 
in  adults.  One  or  both  glands  may  be  affected.  Large  cysts 
2  in.  in  length  'may  thus  be  formed.  If  not  opened  the  cyst 
ruptures  into  the  bulbous  urethra. 

The  symptoms  caused  are  a  chronic  discharge,  obstruction 
to  the  flow  of  urine,  and  a  feeling  of  weight. 

Treatment  consists  in  incising  the  cyst  through  the  urethro- 
scope tube  and  applying  the  electric  cautery  to  the  interior  of 
the  sac. 

CARUNCLE 

Urethral  carmicles  are  found  in  the  female  urethra  on  its 
posterior  wall,  near  or  at  the  meatus.  They  are  vascular  tumours 
covered  with  squamous  epithelium.  The  chief  symptom  is  pain, 
which  varies  very  greatly  in  severity,  and  is  excited  by  walking 
and  other  movements,  and  causes  dyspareunia.  There  are  pain 
and  difficulty  in  micturition,  and  occasionally  complete  retention. 
Haemorrhage  may  occur,  usually  as  terminal  haematuria. 

The  caruncle  forms  a  small  red  tumour  which  appears  at  the 
posterior  lip  of  the  urethral  orifice,  and  may  extend  some  distance 
along  the  posterior  wall  of  the  urethra. 

Excision  is  the  only  treatment,  and  the  operation  should  be 
carefully  performed  by  dissecting  the  whole  of  the  tumour  away 
after  dilating  the  canal.  Recurrence  is  usually  due  to  incomplete 
removal.  I  have  had  to  spht  the  urethra  into  the  vagina  in  order 
thoroughly  to  remove  a  recurrent  caruncle.  The  canal  was  care- 
fully repaired. 

MALIGNANT  GROWTHS  OF  THE  MALE  URETHRA 

Mahgnant  growths  of  the  male  urethra  are  rare.  Preiswerk 
collected  42  undoubted  examples,  and  in  a  collection  made  by 


660  THE  URETHRA  [chap. 

Hall  there  are  6  cases  which  were  not  included  among  these, 
making  a  total  of  48.  Barney  records  2  cases,  and  I  have  had 
3  under  my  care. 

The  condition  is  rare  before  the  age  of  40  (Hutchinson,  one 
case  at  22;  Possi,  one  at  25),  and  is  most  frequently  observed 
between  50  and  60. 

Trauma  has  been  noted  as  a  predisposing  cause,  the  new 
growth  developing  in  a  urethra  the  seat  of  traumatic  stricture. 
Leucoplakia  resulting  from  chronic  urethritis  is  an  important 
precancerous  condition.  The  columnar  epithelium  of  the  urethra 
becomes  transformed  into  squamous  epithelium,  forming  patches 
of  leucoplakia.  Halle  has  traced  the  development  of  epithelioma 
from  these.'    Stricture  is  present  in  about  half  the  cases. 


Fig.  202. — Epithelioma  of  urethra  on  lateral  wall  of 
fossa  navicularis. 

Pathological  anatomy. — The  bulbous  urethra  is  the  seat 
of  the  growth  in  the  majority  of  cases,  the  penile  urethra  (Fig. 
202)  is  less  frequently  affected,  and  the  prostatic  urethra  very 
rarely.  The  growth  may  spread  from  the  bulbous  urethra  to  the 
penile,  or  from  the  penile  to  the  bulbous,  and  a  growth  removed 
from  the  bulbous  -urethra  has  recurred  four  years  later  in  the 
prostatic. 

The  growth  spreads  along  the  mucous  membrane,  infiltrating 
and  destrojdng  it,  and  invades  the  corpus  spongiosum.  A  stricture 
is  usually  present  in  front  of  the  growth.  Posner  found  that  12 
out  of  20  cases  had  pre-existing  gonorrhoeal  stricture.  The  urethra 
is  dilated  behind  the  stricture  with  deposits  of  phosphatic  material 
on  the  mucous  membrane.  The  periurethral  tissues  become  infil- 
trated, and  fistulse  form  on  the  surface  of  the  perineum.     A  malig- 


Fig.   1. — Papilloma  of  anterior  urethra.     (P.  656.) 

Fig.  2. — Polypus    of  posterior  urethra  attached  to  premon- 
tanal  ridge.     (P.   659.) 

Fig.  3. — Urethroscopic       view      of     polypus     of      urethra. 
(P.  659.) 

Fig.  4. — Malignant    growth    of    anterior    urethra   appearing 
through  a  stricture.     (P.  661.) 


Plate  41. 


LT]        MALIGNANT  GROWTH  OF  URETHRA      661 

nant  ^'owth  may  develop  when  fistulsD  are  already  present,  and 
is  said  to  originate  occasionally  in  the  fistulse. 

The  fistula)  may  open  on  the  perineum,  scrotum,  pubis,  or 
buttock,  or  in  the  rectum. 

The  growth  takes  the  form  of  a  squamous  epithelioma.  Sar- 
coma has  very  rarely  been  observed. 

Symptoms. — These  vary  considerably  in  different  cases. 

Increasing  difficulty  in  micturition  is  usually  noted,  and  is 
partly  due  to  a  fibrous  stricture  already  present.  Complete  re- 
tention may  supervene. 

Haemorrhage  may  occur  after  the  passage  of  an  instrument, 
or  may  appear  at  the  meatus  as  a  bloody  discharge  without  instru- 
mentation, or  there  may  be  hsematuria.  In  one  case  under  my 
care  hsematuria  was  severe,  and  there  were  several  attacks  of 
retention  of  urine.  The  growth  was  situated  in  the  prostatic 
urethra,  and  examination  by  the  urethroscope  and  cystoscope 
failed  owing  to  haemorrhage.  A  purulent  discharge,  mixed  with 
blood,  is  very  frequently  present.  In  two  of  my  cases  this  had 
been  mistaken  for  gonorrhoea  before  I  examined  them. 

A  swelling  appears  in  the  perineum  in  some  cases,  and  the 
skin  becomes  red,  and  either  a  fistula  forms  spontaneously,  or 
the  swelling  is  incised  for  a  simple  periurethral  abscess.  The 
growth  then  fungates,  or  progressive  destruction  by  ulceration  of 
the  perineal  tissues  takes  place. 

In  the  penile  urethra  hard  induration  of  the  wall  of  the  canal 
is  felt,  and  this  slowly  increases  and  eventually  involves  the  peri- 
urethral tissues,  spreading  towards  the  dorsum,  and  the  corpora 
cavernosa  become  invaded.  The  penis  may  be  ventrally  curved 
during  erection.  It  becomes  swollen  and  rounded,  and,  when  the 
growth  is  at  the  anterior  part  of  the  urethra,  may  assume  a  club- 
like form. 

Examination  of  the  urethra  with  an  instrument  shows  a  fibrous 
stricture  in  most  cases.  The  instrument  may  pass  this  obstruc- 
tion, but  is  arrested  in  an  irregular  cavity  with  friable,  readily 
bleeding  walls.  Nothing  abnormal  can  be  detected  on  rectal 
examination. 

Urethroscopy  may  give  a  view  of.  the  growth.  It  is  frequently 
impossible  on  account  of  haemorrhage,  as  in  two  cases  of  my  own. 
In  my  third  case  a  tough,  fibrous  stricture  was  present  in  the  penile 
urethra,  and  through  this  were  seen  deep-red  irregular  nodules 
which  were  recognized  as  part  of  a  malignant  growth.  (Plate  41, 
Fig.  4.) 

Lymph-glands,  inguinal  and  ifiac,  are  enlarged  in  only  one- 
third  of  cases,   and  are  affected  late. 


662 


THE   URETHRA 


[chap. 


Course. — The  growth  may  spread  very  rapidly  and  death 
take  place  some  months  after  the  first  appearance  of  symptoms. 
In  other  cases  the  progress  is  slower  and  extends  over  some  years. 
Metastases  occur  in  bones  (ribs,  vertebree),  liver,  and  limgs.  In 
one  of  my  cases  there  was  slow  growth  for  two  years,  and  then 
rapid  generahzation. 

Diagfnosis. — From  stricture  of  the  penile  urethra  the  diagnosis 

is  usually  difiicult.  Spontane- 
ous hfemorrhage  from  the  ure- 
thra, repeated  severe  haemor- 
rhage after  instrmnentation, 
and  persistent  hsematuria  are 
important  symptoms. 

Extensive  infiltration  of  the 
penile  urethra  may  be  observed 
in  subacute  and  chronic  ure- 
thritis ;  when  it  is  progressive, 
and  the  discharge  is  blood- 
stained, and  the  patient  over 
40,  the  diagnosis  of  gro'oi:h  is 
probable. 

In  cases  in  which  there  is  a 
urethral  discharge  with  a  swell- 
ing in  the  perineum  the  diag- 
nosis of  periurethral  abscess  is 
usually  made,  and  the  nature 
of  the  disease  is  only  diagnosed 
after  the  swelKng  has  been 
incised,  and  sometimes  not 
until  some  weeks  later,  when 
healing  is  delayed  and  ulcera- 
tion around  the  perineal  wound 
has  commenced.     (Fig.  203.) 

Treatment. — Eesection  of 
the  urethra  has  been  performed 
in  the  earlv  stage.  In  a  case  recorded  by  Oberlander,  Kuffrecht 
excised  a  gro\^i:-h  of  the  bulbous  urethra,  mth  1^  cm.  on  each  side 
of  it.  and  united  the  cut  ends  of  the  urethra.  Four  and  a  half 
vears  later  the  tumour  recurred  in  the  prostatic  urethra. 

Similar  operations  have  been  performed  by  Konig,  Trzebicki, 
and  others.  When  the  penile  urethra  is  involved  by  a  small 
growth,  amputation  of  the  penis  has  given  good  results  ;  but 
when  the  gro^^i:h  is  extensive,  or  when  it  involves  the  bulbous 
urethra,  complete  removal  of  the  penis  (Thiersch-Gould  operation) 


Fig.  203. — Malignant  growth  of 
urethra  ulcerating  on  perineum 
and  scrotum,  and  round  anus. 


Lil        MALIGNANT  GROWTH  OF    URETHRA      663 

is  necessaiy.  In  the  majority  of  cases  the  tissues  around  the 
corpus  spongiosum  are  infiltrated  and  the  growth  is  inoperable 
when  they  come  under  observation. 

NEW  GROWTHS  OF   COWPER'S  GLANDS 

These  are  very  rare,  only  three  cases  being  recorded,  two  of 
which  were  said  to  be  "  cylindroma."  The  symptoms  are  pain 
and  difficult  micturition  and  complete  retention.  A  tumour 
appears  in  the  perineum,  which  can  be  felt  from  the  rectum,  and 
is  at  first  unilateral.  The  growths  were  excised  in  all  cases,  but 
the  after-history  is  unrecorded. 

MALIGNANT  GROWTHS  OF  THE  FEMALE  URETHRA 

The  condition  is  rare.  Karaki  collected  53  cases,  34  being 
periurethral  or  vulvo-urethral  and  19  primarily  urethral.  I  have 
met  with  2  cases  belonging  to  the  latter  group.  Whitehouse,  after 
careful  examination  of  published  cases,  found  only  43  undoubted 
cases  where  a  microscopical  report  was  given. 

The  periurethral  growths  occur  after  the  age  of  50,  and  the 
primary  urethral  growths  frequently  under  that  age. 

There  has  been  a  pre-existing  urethral  caruncle  in  several  cases, 
and  the  malignant  growth  probably  took  origin  in  this.  Halle 
found  that  chronic  urethritis  with  leukoplakia  preceded  the  growth 
in  some  cases. 

The  urethral  variety  may  be  pedunculated  or  sessile,  appear- 
ing as  a  dark-red  gi'ape-like  polypus  or  a  nodular  ulcerated  area. 
The  periurethral  variety  originates  at  the  external  meatus,  spreads 
around  the  urethra,  and  extends  to  the  vulva.  It  may  take  an 
ulcerating  or  an  infiltrating  character.  The  majority  of  the 
growths  are  squamous-celled  carcinoma  (27,  Whitehouse),  a  few 
are  columnar-celled  carcinoma  (2),  and  others  are  adeno-carcinoma 
(14),  analogous  to  prostatic  carcinoma  in  the  male  and  arising  in 
the  periurethral  glands.     Sarcoma  is  rare   (Kamann). 

Symptoms. — There  is  pain  on  micturition,  on  coitus,  and  on 
sitting  and  walking,  and  the  pain  radiates  down  the  thighs ;  there 
are  also  frequent  micturition,  difficulty  in  the  act,  and  occasion- 
ally complete  retention.  Incontinence  is  rare.  Hsematuria  is 
usually  present.  Haemorrhage  may  occur  apart  from  micturi- 
tion, on  coughing  or  sneezing. 

On  inspection  a  growth,  pedunculated  or  sessile,  is  seen  at  the 
meatus  or  spreading  on  to  the  walls  of  the  vestibule.  Induration 
can  be  detected,  and  oedema  of  one  or  both  labia  may  develop. 
Lymphatic  glands  are  enlarged. 

Treatment. — The  urethra  may  be  excised  by  a  longitudinal 


664  THE   URETHRA  [chap,  li 

incision  on  the  anterior  wall  of  the  vagiaa.  The  vesical  end  is, 
if  possible,  preserved,  and  is  implanted  in  the  vaginal  wall.  The 
patient  is  continent  after  this  operation,  but  if  it  is  necessary  to 
remove  the  whole  of  the  urethra,  including  the  vesical  orifice,  in- 
continence results,  and  it  is  better  in  such  cases  to  close  the  base 
of  the  bladder  completely  and  establish  permanent  suprapubic 
drainage  {see  p.  549).  One  patient  was  well  without  recurrence 
five  years,  and  another  one  year,  after  removal  of  the  growth. 

LITERATURE 

Barney,  Boston  Jled.  and  Surg.  Journ.,  1907,  p.  790. 

Bouzani,  Folia  Urol.,  1909,  p.  491. 

Cabot,  X.  7.  2Ied.  and  Surg.   Journ.,  1895,  p.  278. 

Ehrendorfer,   Centralbl.  f.  Gyn.,  1892,  Xr.  17. 

Englisch,   Folia  Urol.,  1907,  p.  38. 

Ftlller,   Journ.   Cutan.  and  Gen.-  Vrin.  Dis.,  April,  1895. 

Gussenbauer  und  Pietrzikowski,  Zeits.  f.  Heilhund.,  1885,  vi.  421. 

Hall,  Ann.  Surg.,  1904,  p.  375. 

Halle,  Ann.  d.  Mai.  d.  Org.  Gen.-  TJrin.,  1896,  p.  481. 

Kamann,  Jlonats.  f.  Geh.  u.  Gyn.,  April,  1906. 

Kapsammer.  Wien.  Jdin.  Woch.,  1903,  Xr.  10. 

Karaki,  Zdts.  /.  Gel.  u.  Gyn.,  1908,  p.  151. 

Kocher  und  Kauffmami,  EranJcTieiten  der  miannlichen  Harnrohre.     1886. 

foetschmer,  Trans,  of  Chicago  Path.  Soc,  June  1,  1911,  vol.  viii. 

Labhardt,  Zeits.  /.   Gyn.  u.  Urol.,  1910,  ii.   1. 

McMurty,  Surg.,  Gyn.  and  Obst.,  June,  1908,  vol.  vi. 

Oberlander,  Centralbl.  f.  d.  Krankh.  d.  Ham-  u.  Sex.-Org.,  Aug.,  1893,  Bd.  iv.  ;  and 

1900,  si.  454. 
Pagnet  et  Hermann,  Journ.  de  VAnat.  et  de  la  Physiol.,  1884,  p.  615. 
Plannenstiel,  Centralbl.  f.  Gyn.,  1901,  p.  33. 
Posner,  Zeits.  f.   Krebsforsch.,  1904,  i.  4. 
Preiswerk,  Zeits.  f.  Urol.,  1907,  p.  273. 
Soubeyran,  Gaz.  des  Hop.,  1903,  p.  1181. 
Trzebicki,  Wien.  med.  Woch.,  1884,  p.  606. 
Vineberg,  Amer.  Journ.  Med.  Sci.,  July,  1902. 
Wassermann,  These  de  Paris,  1895. 
Whitehouse,  Proc.  Boy.  Soc.  Med.,  Obstet.  and  Gynsecol.  Sect.,  Jan.,  1912,  p..  128. 


CHAPTER  LII 
TUBERCULOSIS  OF  THE  URETHRA  AND  PENIS 

Tuberculosis  of  the  urethra  is  rare.  Primary  tuberculosis  has 
been  observed,  but  the  infection  is  almost  invariably  secondary 
to  tuberculosis  of  the  urinary  or  genital  systems.  The  female 
urethra  is  very  seldom  affected.  The  usual  form  is  tuberculosis 
of  the  posterior  urethra  in  the  male  ;  the  anterior  urethra  is 
seldom  involved. 

The  prostatic  urethra  is  affected  by  spread  from  the  prostate 
gland  or  from  the  bladder.  A  deep  tuberculous  cavity  may  open 
from  the  substance  of  the  prostate  on  the  posterior  urethra,  or 
there  may  be  superficial  ulceration  or  tuberculous  granulation 
tissue.  The  anterior  urethra  may  be  the  seat  of  small  super- 
ficial ulcers ;  but  if  the  penis  is  affected  the  urethral  mucous 
membrane  is  involved  in  the  tuberculous  infiltration. 

The  periurethral  tissues  may  be  imphcated  and  a  '"  cold  ab- 
scess "  form,  and  eventually  fistulse  appear  in  the  perineum.  The 
prevesical  space  may  also  be  involved.  Enghsch  has  described 
tuberculosis  of  Cowper's  glands. 

Stenosis  of  the  urethra  is  occasionally  observed  in  the  bulbous 
or  penile  urethra  in  cases  of  urinary  and  genital  tuberculosis. 
There  is  seldom  a  localized  stricture  such  as  is  found  as  the  result 
of  gonorrhoeal  urethritis.  The  wall  is  infiltrated,  and  an  irregular 
fibrous  thickening  of  the  mucous  membrane  results. 

Symptoms. — A  urethral  discharge  is  always  present,  and  is 
usually  thin  and  pale,  but  occasionally  it  is  so  abundant  and 
purulent  and  the  s}Tnptoms  are  so  acute  as  to  suggest  gonorrhoeal 
urethritis.  Gonococci  are,  however,  absent,  and  tubercle  bacilli 
are  found.  Heematuria,  frequent  and  difl&cult  micturition,  and 
occasionally  complete  retention,  may  be  present.  There  is  irregular 
periurethral  induration,  and  a  bougie  passed  along  the  urethra 
meets  resistance,  and  grating  may  be  felt.  Haemorrhage  frequently 
follows. 

With  the  urethroscope  infiltration  and  occasionally  ulceration  are 
seen.  A  deep  tuberculous  ca^-ity  or  superficial  ulceration  or  tuber- 
culous granulation  tissue  may  be  found  in  the  posterior  urethra. 

665 


666  THE   URETHRA  [chap,  lii 

Tuberculosis  of  the  penis  may  be  confined  to  ulceration  of  the 
glans,  usually  on  the  under  surface,  or  the  corpora  cavernosa  of 
the  penis  may  be  invaded.  In  a  case  under  my  care  the  terminal 
two-thirds  of  the  penis  was  greatly  enlarged,  round,  and  hard, 
and  the  glans  penis  showed  several  sinuses  through  which  granula- 
tion tissue  projected.  The  first  2|  in.  of  the  urethra  were  in- 
volved. No  other  tuberculous  lesion  was  detected  in  the  genital 
or  urinary  system. 

Treatment. — Tuberculosis  of  the  urethra  is  so  seldom  an 
isolated  lesion  that  separate  treatment  is  rarely  necessary. 

Internal  urethrotomy  should  be  performed  in  stenosis  of  the 
urethra,  and  instruments  passed  at  short  intervals  afterwards,  as 
there  is  a  marked  tendency  to  recontraction.  When  a  "cold 
abscess"  forms  it  should  be  opened,  and  tincture  of  iodine  applied 

Fistulse  are  treated  by  scraping  and  injection  of  iodoform 
emulsion,  bismuth  paste,  or  iodine. 

Conservative  treatment  should  be  adopted  when  the  penis  is 
involved,  but  amputation  may  become  necessary  for  extensive 
lesions.  Tuberculin  (T.R.)  should  be  given  in  gradually  increasing 
doses  in  all  cases,  and  should  be  persisted  in  for  periods  of  many 
months  or  several  years. 

Where  there  is  extensive  destruction  of  the  urethra,  with 
tuberculosis  of  the  bladder,  permanent  suprapubic  drainage  of 
the  bladder  may  become  necessary  in  order  to  relieve  the  constant 
pain  and  vesical  spasm. 

LITERATURE 

Asch,  Zeits.  /.   XJrol.,  1909,  iii.  174. 

Chute,  Boston  Med.  and  Surg.   Journ.,  1903,  p.  361. 

Halasz,   Ungarische  mediz.  Pres.se,  1901,  p.  762. 

Hallg  et  Motz,  Ann.  d.  Mai.  d.  Org.   Gen.-  Urin.,  1902,  p.  1464. 

Hogge,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1901,  p.  1491. 

Sawamiira,  Folia  Urol.,  1910,  iv.  683. 


PART  V,—THE  PR0STA7E 

CHAPTER  LIII 

SURGICAL  ANATOMY—EXAMINATION 
CONGENITAL  MALFORMATIONS 

SURGICAL  ANATOMY 

The  prostate  gland  is  the  size  and  shape  of  a  Spanish  chestnut, 
and  lies  with  its  long  axis  vertical,  its  base  beneath  the  floor  of 
the  bladder,  and  its  apex  at  the  triangular  ligament,  ^f  in.  below 
and  behind  the  subpubic  angle.  Its  average  weight  is  4|  drachms, 
and  it  measures  1^  in.  in  length,  1  in.  in  the  antero-posterior 
diameter,  and  1^  in.  transversely.  The  base  lies  beneath  the  floor 
of  the  bladder,  extending  backwards  behind  the  urethra  to  about 
the  mid-point  of  the  trigone  and  forwards  for  J  in.  in  front  of 
the  internal  meatus.  The  greatest  lateral  extent,  which  measures 
V  in.  on  each  side,  is  a  line  drawn  from  the  internal  meatus 
outwards  and  a  little  backwards.  The  glandular  tissue  of  the 
prostate  lies  behind  and  on  each  side  of  the  urethra,  and  does  not 
project  in  front  of  it. 

The  arrangement  of  bladder  muscle  on  the  base  of  the  pros- 
tate is  as  follows  :  The  outer  longitudinal  layer  of  bladder  muscle 
(Fig.  206)  loses  itself  upon  the  upper  surface  of  the  gland,  the  muscle 
fibres  becoming  incorporated  vath.  the  non -striped  muscle  of  the 
stroma  of  the  organ.  Lying  upon  this  is  the  trigone  muscle,  con- 
sisting of  a  layer  of  transversely  disposed  muscle  fibres,  which 
forms  a  thick  wedge  behind  the  opening  of  the  urethra  and  is 
continued  into  the  outer  circular  muscular  layer  of  the  urethra. 
Over  this  muscular  layer  is  a  longitudinal  layer  continuous  with 
the  inner  longitudinal  layer  of  the  ureters  and  passing  into  the 
internal  longitudinal  layer  of  the  urethra.  In  front  of  the  urethra 
the  outer  longitudinal  layer  of  bladder  muscle  approaches  the 
anterior  wall  of  the  urethra,  and  becomes  lost  among  the  bundles 
of  circular  muscle  which  surround  it.  The  inner  or  circular  layer 
of  bladder  muscle  is  continued  well  up  to  the  urethra,  and  then 
ceases. 

6G7 


668 


THE  PROSTATE 


[chap. 


Along  the  anterior  wall  of  the  urethra  is  a  thick  layer  of  cir- 
cular muscle  which  extends  from  the  base  to  the  apex  of  the  pros- 
tate. The  true  sphincter  of  the  bladder  consists  of  the  circular 
trigone  muscle  behind  the  urethra,  which  spreads  out  fan-wise 
on  each  side  of  the  prostatic  urethra  and  forms  the  vertical  band  of 
circular  muscle  in  front  of  this  portion  of  the  urethra.  Surrounding 
the  membranous  urethra  at  the  apex  of  the  prostate  is  the  com- 
pressor urethrse  muscle,  and  the  striped  fibres  of  this  muscle  are 
continued  upwards  (Henle's  muscle)  on  the  anterior  surface  of  the 


Fig.  204. — Bladder  and  prostate  with  pelvic  fascia. 

f  anterior  surface  of  nrostate  between  reflected    lateral   lavers  of   sheath.     B. 


A,  Part  of  anterior  surface  of  prostate  between  reflected  lateral  layers  of  sheath.  B,  Anterior 
wall  of  bladder.  C,  C,  Recto-vesical  layer  of  pelvic  fascia  on  upper  surface  of  levator  ani  muscle. 
D,  D,  Vertical  line  of  reflection  of  fascia  on  anterior  surface  of  prostate.  E,  Line  of  reflection  of 
fascia  crossing  middle  line.  F,  F,  Upper  layer  of  triangular  ligament.  G,  Apex  of  prostate  with 
termination  of  dorsal  vein  of  penis.   H,  Striped  muscle  round  urethra.  J,  Urethra.   K,  K,  Levator 

ani  muscle. 

prostate  gland  as  far  as  the  base.  The  striped  muscle  lies  between 
the  anterior  commissure  and  the  anterior  layer  of  the  sheath  con- 
taining the  ascending  portion  of  the  prostatic  plexus.  Laterally 
some  fibres  stray  among  the  non-striped  fibres  of  the  prostatic, 
stroma,  but  the  layer  may  be  traced  on  each  side  on  the  surface 
of  the  capsule  as  far  back  as  the  level  of  the  urethra. 

The  prostate  is  surrounded  by  a  layer  of  fascia,  which  envelops 
it  except  at  its  basal  attachment  to  the  bladder.  (Fig.  204.)  At  the 
apex  the  fascia  blends  with  the  muscular  tissue  around  the  urethra. 
This  sheath  is  derived  from  the  recto-vesical  layer  of  pelvic  iascia. 


LIIl] 


SURGICAL  ANATOMY 


669 


and  is  formed  in  the  following  manner :  The  recto-vesical  layer  of 
pelvic  fascia  passes  inwards  from  the  side  wall  of  the  pelvis  and 
meets  the  lateral  aspect  of  the  junction  of  the  bladder  and  pros- 
tate, and  from  this  a  strong  layer  of  fascia  passes  downwards  over 
the  lateral  aspect  of  the  prostate,  forming  the  lateral  portion  of 
the  sheath.     The  lateral  layer  leaves  the  gland  on  each  side  before 
it   reaches   the   middle   line   anteriorly,  so    that  a  vertical   band 
on  the  anterior  sur- 
face of  the  prostate 
is     left    uncovered.      | 
Those    layers  unite      ' 
across    the     middle 
line  at  the  apex   of 
the  prostate  to  form 
the  upper   layer   of 
the  triangular  liga- 
ment.  The  posterior 
surface  of  the  pros- 
tate is  covered  by  a 
layer  of  fascia  which 
sphts  off   from   the 
recto-vesical    fascia, 
and      is      attached 
along  the  base,  send- 
ing   a    prolongation 
upwards     to    cover 
the  seminal  vesicles 
and     the     terminal 
portions  of  the  vasa 
deferentia   and  ure- 
ters.     The      fascial 
sheath    can    be 
stripped,   without 
damage  to  the  gland, 
from  the  lateral  and 
posterior  surfaces.     (Fig.  205.)     It  is  adherent  around  the  base 
and  at  the  apex  and  along  the  anterior  surface. 

The  prostatic  urethra  traverses  the  gland.  The  first  part  of 
the  tube  from  the  internal  meatus  to  the  verumontanum  is  straight 
and  vertical.  At  the  verumontanum  the  urethra  begins  to  curve 
forwards,  and  the  remaining  part  of  its  course  is  as  much  forwards 
as  downwards.  At  the  internal  meatus  the  urethra  lies  on  the 
same  vertical  plane  as  the  anterior  borders  of  the  lateral  lobes. 
From  this  level  it  sinks  backwards  in  relation  to  the  gland  tissue. 


--D 


Fig,  205. — Lateral  view  of  prostate  and 
fascia. 

A,  Right  lobe  of  prostate  exposed.  B,  Bladder.  C,  Line  of 
attachment  of  recto-vesical  layer  of  fascia.  D,  Line  of  reflec- 
tion of  fascia  from  prostate.  E,  Levator  ani  muscle.  V, 
Lateral  layer  of  fascial  sheath  thrown  back.  A  probe  has 
been  passed  behind  the  prostate  within  the  sheath. 


670 


THE  PROSTATE 


[chap. 


so  that  at  the  verumontanum  it  lies  midway  between  the  anterior 
and  posterior  surfaces  of  the  organ.  From  this  point  it  passes 
more  and  more  towards  the  front  of  the  organ  as  the  gland  tubules 
disappear. 

The  structure  of  the  prostate  gland  consists  of  tubules  embedded 
in  a  densely  woven  stroma  of  non-striped  muscle.  There  is  no 
distinct  circular  arrangement  of  the  fibres  of  the  stroma  around 
the  individual  tubules.  At  the  surface  of  the  organ  there  is  an- 
area  of  stroma  in  which  no  gland  tubules  can  be  seen,  and  the 
fibres  are  more  circular  in  their  arrangement.     This  is  the  true 


Fig.  206. — Vertical  mesial  section  through  bladder  base, 
prostate,  and  surroundings. 

A,  A,  Circular  layer  of  bladder  muscle.  B,  B,  Longitudinal  layer  of  bladder  muscle.  C,  Circular 
layer  of  trigone  muscle.  D,  D,  Unstriped  sphincter  of  bladder.  B,  Longitudinal  layer  of  trigone 
muscle.  F,  Urethra.  G,  Seminal  vesicle.  H,  Ejaculatory  duct.  J,  Prostatic  gland  tissue. 
K,  Striped  muscle  in  front  of  prostate.     L,  Veins  of  prostatic  plexus.     M,  Rectum.     Q,  Recto- 

urethral  muscle. 

capsule  of  the  prostate.  The  gland  tubules  are  arranged  in  horse- 
shoe form  around  the  posterior  and  lateral  aspects  of  the  urethra, 
and  form  two  lobes.  In  stained  transverse  sections  of  the  pros- 
tate no  division  of  the  gland  tissue  into  two  lobes  can  be  seen 
behind  the  urethra.  (Fig.  207.)  In  front  of  the  urethra  along  the 
whole  length  of  the  prostate  is  a  vertical  wedge  of  non-striped 
muscle  and  fibrous  tissue.  This  anterior  commissure  separates 
the  two  lateral  lobes. 

From  the  verumontanum  a  band  consisting  of  the  sinus  pocularis 
and  the  ejaculatory  ducts,  surrounded  by  a  sheath  of  non-striped 


LIII 


SURGICAL  ANATOMY 


671 


muscle,  passes  upwards  and  backwards  through  the  sheet  of  gland 
tissue  which  unites  the  lateral  lobes  behind  the  urethra.  In  a 
vertical  median  section  this  band  appears  to  isolate  a  wedge  of 
gland  lying  immediately  behind  the  upper  part  of  the  urethra. 
This  is  the  so-called  "  median  lobe."  No  separate  lobe  exists  in 
the  nornaal  prostate.  The  ducts  of  the  prostatic  glands  open  into 
the  I  prostatic  sinuses  in  the  immediate  neighbourhood  of  the 
verumontanum,  and  on  the  posterior  wall  of  the  urethra  above 
this.     No   gland  ducts  open  into  the  urethra  between   the  part 


Fig.  207. — Transverse  section  of  prostate  and  surroundings 
at  level  of  verumontanum. 

A,  Anterior  wall  of  rectum.  B,  Areolar  tissue.  C,  C,  Visceral  layer  of  pelvic  fascia.  D,  Sheath 
of  prostate  formed  by  pelvic  fascia.  E,  Sheath  of  prostate.  F,  Pelvic  fascia  (sheath)  reflected 
from  anterior  surface  of  prostate.  G.  G,  Levator  ani  muscle.  H,  Fibrous  [tissue  on  anterior 
surface  of  prostate.  I,  Large  veins  of  prostatic  plexus.  K,  Striped  muscle  layer  on  anterior 
surface  of  prostate.  L,  M,  Capsule  of  prostate.     N,  Anterior  commissure.     O,  Verumontanum. 

P,  Ejaculatory  ducts. 

immediately  adjacent  to  the  verumontanum  and  the  membranous 
urethra. 

Although  the  lateral  lobes  are  not  separated  histologically, 
they  are  physiologically  distinct.  Acute  inflammation  and  malig- 
nant disease  may  be  accurately  limited  to  one  lobe,  the  other  lobe 
being  healthy. 

The  arteries  supplying  the  prostate  are  derived  from  the 
vesical,  hgemorrhoidal,  and  pudic  arteries. 


672 


THE   PROSTATE 


[chap. 


The  veins  form  the  prostatic  venous  plexus  (Figs.  208,  209). 
This  commences  in  the  dorsal  vein  of  the  penis,  and,  passing  up  the 


Fig.  208. — Prostatic  plexus  of  veins,  anterior  view. 

A,  A,   Anterior   surface    of  prostate.     B    Bladder.      C,    Termination  of  dorsal    vein    of  penis. 
D,    Prostatic   plexus.     E,    E,   Vesico-prostatic    plexuses.     The   dotted  line    shows   the   line    of 

attachment  of  fascia. 


Fig.  209. — Prostatic  plexus  of  veins,  side  view. 

A,  Right  lobe    of  prostate.     B,  Bladder.     D,  Prostatic  plexus  on  anterior  surface   of 

prostate.      E,    Vesico-prostatic   plexus.      F,  End   of   right   seminal    vesicle.     G,  Vas 

deferens.     H,  Right  ureter. 

anterior  surface  of  the  prostate  from  the  apex  to  the  base,  here 
splits  into  two  groups,  which  pass  along  each  side  at  the  angle 
formed  by  the  junction  of  the  bladder  and  prostate.    The  plexus  is 


Liii]  EXAMINATION   OF   PROSTATE  673 

thus  shaped  Uke  the  letter  Y.  On  the  front  of  the  prostate  the  stem 
of  the  Y  is  formed  by  large  intercommunicating  venous  channels 
embedded  in  the  anterior  layer  of  the  fibrous  sheath  and  separated 
from  the  anterior  commissure  of  the  prostate  by  the  layer  of  striped 
muscle  described  above.  The  arms  of  the  plexus  receive  the 
vesical  veins  and  those  from  the  seminal  vesicles,  and  pass  to  the 
internal  iliac  vein. 

The  lymphatics  pass  in  trunks  with  the  veins  to  glands  situated 
along  the  internal  iliac  vessels  and  at  the  bifurcation  of  the  iliac 
artery.  A  few  pass  to  glands  in  front  of  the  bladder,  and  some 
lymphatic  vessels  pass  round  the  rectum  to  a  gland  in  the  hollow 
of  the  sacrum  and  upwards  to  the  aortic  chain. 

The  nerves  are  derived  through  the  hypogastric  plexus  from 
the  3rd  and  4th  sacral  nerves. 

LITERATURE 

Albarran,  Medecine  Operatoire  des  Voies  Urinaires.     1909. 

Kalischer,  Die  Urogenitalmuskulatur  des  Dammes.     1900. 

Proust,  La  Prostatectomie.     1904. 

Walker,  Thomson,  Med.-Chir.   Trans.,  1904,  vol.  Ixxxvii.  ;    Brit.  lied.    Journ., 

July  9,  1904 ;    Journ.  of  Anat.  and  Phijs.,  190G,  xl.  189. 
Ziegler,  These  de  Bordeaux,  1893. 
Zuckerkandl,   E.,  Handbuch  der  Urologie   (von   Frisch  und  Zuckerkandl),    1904, 

Bd.  i. 

EXAMINATION  OF  THE  PEOSTATE 

Rectal  examination  (Fig.  210)  may  be  performed  with  the 
patient  in  the  knee-elbow  position  on  a  couch,  or  lying  on  his  back 
with  the  pelvis  raised  in  the  lithotomy  position.  The  former  is 
preferable  for  routine  examination,  while  the  latter  is  used  in  ex- 
amination under  general  anaesthesia  and  for  bimanual  examination. 

On  introduction  of  the  forefinger,  covered  with  a  thin  rubber 
glove  and  well  oiled,  a  pocket  is  felt  on  the  anterior  wall  of  the 
rectum  immediately  internally  to  the  anal  canal.  A  vertical  ridge 
in  the  middle  line  of  this  pouch  is  the  membranous  urethra ;  on 
each  side  of  this  is  a  depression  in  the  position  of  Cowper's  glands, 
which  can  be  felt,  when  enlarged,  by  pressing  the  thumb  on  the 
perineum  and  grasping  the  tissues  between  this  and  the  finger 
in  the  rectum.  The  prostate  is  felt  above  this  anterior  pouch, 
and  in  the  great  majority  of  cases  the  finger  easily  reaches  above 
the  upper  limit  of  the  gland.  Difficulty  may  be  experienced  when 
the  buttocks  are  heavy  and  the  perineum  deep,  and  when  the 
patient  is  nervous  and  rigidly  contracts  his  muscles.  In  the  middle 
line  of  the  prostate  is  a  vertical  groove,  and  on  each  side  of  this 
a  prostatic  lobe  is  felt. 

The  consistence  of  the  normal  prostate  is  miiform  and  elastic, 
2r  . 


674  THE  PRQSTA.TE  [chap. 

and  pressure  causes  a  slight  desire  to  micturate.  The  gland  has 
a  moderate  degree  of  mobility,  which  is  best  appreciated  by  com- 
paring it  with  a  prostate  the  seat  of  malignant  growth.  On  each 
side  of  the  gland  is  a  sulcus,  the  depth  of  which  indicates  the  antero- 
posterior size  of  the  prostate.  The  finger  should  search  for  tough- 
ness or  hardness  of  the  gland,  for  nodules  projecting  or  buried, 
for  enlargement,  lateral  spread,  vertical  spread,  for  diminution  of 
mobility,  for  tenderness,  for  obliteration  of  the  paramembranous 
depressions. 

The  track  along  which  lymphatics  of  the  prostate  pass  is  felt 
as  a  sling  which  leaves  the  upper  part  of  the  lateral  lobe  on  each 
side  and  passes  upwards  and  outwards.  In  carcinoma  of  the 
prostate  thickening  may  be  felt  in  this  situation,  and  a  nodule  or 


:<-\  ,>'>^ 


SEMIN/iL    VESICLE 
PR03T/ITE 


_         COh'PER5    OLfiND 
"-MEMBRANOUS     UR^THR/^ 

Fig.  210.- — Structures  in  relation  to  anterior  wall  of  male  rectum. 

The  parts  normally  felt  on  rectal  examination  are  shown  in  continuous  black  lines  ;  those  felt  in 
disease  are  shown  in  dotted  lines. 

a  chain  of  nodules,  representing  small  lymphatic  glands  con- 
tainirig  deposits.  In  a  very  lax  bladder  the  upper  surface  of  the 
gland  can  sometimes  be  palpated. 

The  seminal  vesicles  lie  immediately  above  the  base  of  the 
prostate.  They  pass  transversely  outwards  and  upwards,  and 
are  readily  palpated  by  a  finger  of  ordinary  length.  They  may 
be  empty  and  cannot  be  felt,  or  distended  and  form  soft,  sausage- 
like cushions.  Nodules  and  thickening  of  the  wall  should  be  searched 
for.  When  malignant  growth  or  chronic  cellulitis  has  obliterated 
the  lateral  sulci,  a  level  surface  is  felt  on  the  anterior  wall  of  the 
rectum,  in  which  the  outline  of  the  organs  is  wanting. 

In  bimanual  examination  the  patient  is  in  the  lithotomy 
position,  and  the  left  hand  presses  downwards  above  the  pubic 
symphysite.  An  enlarged  prostate  can  frequently  be  felt  in 
this  wav. 


Till]  CONGENITAL   MALFORMATIONS  675 

Rectal  examination  in  the  recumbent  position  may  be  assisted 
by  the  passage  of  a  metal  sound,  which  can  be  felt  in  the  median 
furrow. 

The  length  of  the  prostatic  urethra  may  be  measured  by  pass- 
ing a  coude  catheter.  The  sensation  given  to  the  surgeon's  fingers 
on  passing  the  catheter  will  show  when  the  point  encounters  the 
resistance  of  the  compressor  urethree  muscle  at  the  membranous 
urethra,  and  passes  through  this  into  the  prostatic  urethra.  There 
is  again  slight  resistance  when  the  point  passes  through  the  inter- 
nal meatus,  and  the  urine  now  begins  to  flow,  showing  that  the 
eye  of  the  catheter  is  in  the  bladder.  In  some  forms  of  enlarge- 
ment of  the  prostate  the  upper  part  of  the  prostatic  urethra  is 
open  and  trumpet-shaped,  and  this  test  is  fallacious.  A  metal 
stone  sound  may  be  used  for  this  purpose.  The  beak  is  turned 
downwards  after  entering  the  bladder,  and  withdrawn  until  it 
hitches  on  the  prostate.  A  calculus  projecting  from  a  pouch  in 
the  prostate  or  lying  in  the  prostatic  urethra  will  be  felt  with  the 
sound. 

The  cystoscope  gives  information  in  regard  to  the  urethral 
orifice  and  the  upper  surface  of  the  prostate.  In  the  normal 
state  the  margin  of  the  urethra  is  slightly  concave  upwards.  In 
enlargement  of  the  prostate  it  is  convex.  A  central  lobe  or  lateral 
intravesical  projection  may  be  seen,  and  the  size  and  extent 
estimated  by  the  projection  hiding  part  or  the  whole  of  the  trigone 
from  view  and  obscuring  the  view  of  the  ureteric  orifices. 

An  irregular  projection  is  seen  in  malignant  disease  of  the 
prostate,  and  a  malignant  growth  may  be  seen  ulcerating  through 
the  bladder  base  from  the  prostate. 

CONGENITAL  MALFORMATIONS 

Complete  absence  of  the  prostate  is  rare,  and  only  occurs  in 
combination  with  other  malformations  of  the  genital  organs,  such 
as  ectopia  vesicae,  pseudo-hermaphroditism,  hypospadias,  absence 
of  the  testicle. 

Congenital  and  Acquired  Cysts 

Cysts  of  the  prostate  are  found  in  children  a  few  days  after 
birth,  due  to  closure  of  the  opening  of  the  sinus  pocularis  and 
retention  of  the  secretion.  The  verumontanum  is  enlarged,  and 
the  cyst  projects  into  the  prostatic  urethra.  It  may  attain  a 
considerable  size,  and  can  be  felt  on  the  rectal  surface  of  the  pros- 
tate as  a  rounded  swelling.  There  is  a  lining  of  columnar  epithe- 
lium, and  the  contents  are  fluid,  with  epithelial  and  romid  cells. 
The  cyst  wall  is  thin  and  easily  ruptured  into  the  urethra,  or  it 


676  THE  PROSTATE  [chap,  liii 

may  be  thick  and  resistant.  Such  cysts  cause  urethral  obstruc- 
tion and  retention  of  urine.  Cysts  developing  between  the  pros- 
tate and  rectum  are  ascribed  by  Englisch  to  vestigial  remains  of 
the  duct  of  Miiller  when  their  position  is  median,  and  of  the  Wolffian 
body  when  laterally  placed.  They  are  found  in  adults,  and  cause 
no  symptoms  when  small,  but  large  cysts  may  give  rise  to  symp- 
toms of  pressure  on  the  bladder  or  rectum,  to  retention  of  urine, 
or  to  radiating  pain  in  the  testicles  and  thighs.  A  large  cyst  may 
be  mistaken  for  a  distended  bladder  or  for  a  vesical  diverticulum. 
The  diagnosis  is  made  by  cystoscopy,  and  by  rectal  examination 
with  a  sound  in  the  urethra,  the  bladder  having  been  emptied. 

Treatment  consists  in  exposure  of  the  cyst  from  the  perineum 
and  drainage. 


CHAPTER  LIV 
PROSTATITIS 

Acute  prostatitis  occurs  most  frequently  as  a  complication  of 
gonorrhoea.  Other  predisposing  causes  are  stricture  of  the  urethra, 
cystitis  and  vesical  calculus,  sexual  excess,  various  conditions 
of  the  intestines,  such  as  constipation,  haemorrhoids,  fistula,  and 
dysentery.  Bicycling  is  also  said  to  be  a  predisposing  cause. 
The  exciting  cause  is  frequently  the  passage  of  instruments,  as 
in  dilatation  of  a  stricture,  the  use  of  a  lithotrite  in  vesical  cal- 
culus, or  the  injection  of  strong  solutions  in  the  treatment  of 
urethritis,  or  even  irrigation  of  the  urethra  with  weak  solutions. 

The  infection  usually  reaches  the  prostate  directly  by  way 
of  the  urethra.  Bacteria  are  already  present  or  are  introduced 
by  instruments.  A  hsematogenous  infection  may  rarely  take 
place  as  a  complication  of  parotitis,  smallpox,  and  cellulitis  of  the 
neck.  Acute  prostatitis  may  occur  apart  from  any  known  local 
cause,  and  is  then  usually  part  of  a  hsematogenous  infection  of 
the  urinary  tract  by  the  bacillus  coli  communis  in  cases  of  con- 
stipation or  colitis.  The  bacteria  most  frequently  found  are  the 
staphylococcus,  the  bacillus  coli  communis,  and  the  streptococcus ; 
the  pneumococcus  is  rare.  Certain  anaerobic  bacteria  have  been 
described  by  Albarran,  Cottel,  and  others  in  phlegmonous  inflam- 
mation around  the  prostate.  The  gonococcus  is  very  rarely  found 
alone  ;  Casper  did  not  find  it  in  a  single  instance  in  25  cases  of 
prostatic  abscess  complicating  gonorrhoea.  Oraison  found  it  in  35 
per  cent,  of  cases.  In  the  majority  of  cases  of  prostatic  abscess 
complicating  gonorrhoea  the  infection  is  secondary. 

The  varieties  of  prostatitis  are  acute  prostatitis,  prostatic 
abscess,  and  chronic  prostatitis. 

ACUTE  PROSTATITIS 

Symptoms. — A  slight  degree  of  acute  prostatitis  frequently 
occurs,  and  is  difficult  to  distinguish  from  posterior  urethritis, 
with  which  it  is  invariably  combined. 

There  is  frequent  and  urgent  micturition ;  and  on  passing 
the  urine  into  two  glasses  both  portions  are  cloudy.     The  urine 

677 


678  THE   PROSTATE  [chap. 

contains  comma-threads  which,  are  characteristic  of  prostatic  aiiec- 
tions.  The  threads  consist  of  pus  cells  and  columnar  epithelium, 
and  are  formed  in  the  ducts  of  the  prostatic  glands.  On  rectal 
examination  no  enlargement  of  the  prostate  gland  is  found,  and 
there  "is  little  or  no  tenderness  on  pressure  of  the  gland. 

The  more  severe  form  of  acute  prostatitis  begins  suddenly 
during  an  attack  of  gonorrhoea,  or  after  surgical  interference  in  the 
urethra.  The  patient  feels  ill  and  may  have  one  or  several  slight 
attacks  of  shivering  or  a  fully  developed  rigor.  The  temperature 
rises  to  102°  F.  or  higher,  and  there  are  thirst,  dry  tongue,  anorexia, 
and  constipation. 

The  onset  is  frequently  marked  by  retention  of  urine.  Occa- 
sionally the  symptoms  commence  insidiously. 

There  is  deep,  heavy  pain  in  the  rectum  and  perineum  and 
at  the  end  of  the  penis,  which  is  worse  on  standing,  sitting,  or 
walking,  and  also  on  micturition  and  defeecation.  There  are 
frequent  and  very  painful  attempts  to  pass  water  with  straining. 
If  retention  is  absent  small  quantities  of  urine  are  passed  very 
frequently,  sometimes  with  a  few  drops  of  blood. 

Rectal  examination  shows  enlargement  of  one  or  both  lobes 
of  the  prostate,  the  line  of  enlargement  being  sharply  defined 
when  the  prostatitis  is  unilateral.  The  consistence  is  firm  and 
the  organ  intensely  tender. 

Course  and  prognosis. — Resolution  may  take  place.  The 
symptoms  subside,  and  in  a  week  or  a  fortnight  have  disap- 
peared, but  the  prostate  remains  hard  and  enlarged,  and  the 
infiltration  only  disappears  after  some  months,  or  it  becomes 
chronic. 

Suppuration  may  take  place.  The  pain  becomes  throbbing, 
the  fever  continues ;  the  swelling  increases,  and  a  sensation  of 
deep-seated  fluid  may  be  felt  on  pressure,  and  later  more  distinct 
softening  is  detected. 

Treatment. — All  local  treatment,  such  as  irrigation,  instilla- 
tions, passage  of  instruments,  must  cease.  The  patient  is  confined 
to  bed  and  hot  fomentations  are  applied  suprapubically  and  to 
the  perineum.  A  purge  such  as  calomel  (4  gr.)  should  be  given, 
followed  by  a  sahne.  Hot  rectal  irrigations  should  be  administered 
night  and  morning  (110°-115°  F.),  supplemented  by  injection  into 
the  rectum  of  a  small  enema  (8  or  10  oz.)  of  hot  water  containing 
antipyrin  (20  or  30  gr.)  and  tincture  of  opium  (10  or  15  minims). 
Contrexeville  water  is  administered  by  the  mouth,  sandal-wood  oil 
in  capsules  (10  minims),  and  citrate  of  potash  (20  gr.) ;  belladonna 
and  hyoscyamus  may  also  be  given  to  relieve  the  irritation  and 
spasm. 


Liv]  ABSCESS   OF  PROSTATE  679 

PROSTATIC  ABSCESS 

Latent  abscess  of  the  prostate,  occurring  both  in  enlarged 
prostate  and  in  cases  in  which  hypertrophy  is  absent,  has  been 
described.  It  is  rare,  and  is  only  discovered  on  removal  of  the 
prostate,  or  by  accident  when  palpating  the  gland  in  routine 
examination  in  other  conditions  such  as  chronic  urethritis. 

In  the  majority  of  cases  the  abscess  develops  in  the  course  of 
acute  prostatitis.  The  temperature,  already  raised,  increases  sud- 
denly after  a  chill  or  rigor.  There  are  increased  frequency  and 
difhculty  of  micturition.  The  pain  becomes  more  severe  ;  it  is 
constant,  heavy,  and  throbbing,  and  radiates  to  the  thighs. 

On  rectal  examination  the  prostate,  which  was  already  enlarged, 
is  found  to  have  increased  in  size,  and  deep-seated  softening  may 
be  detected.  Later  a  soft  area  in  the  hard  mass  of  enlarged 
prostate  may  be  easily  detected  as  the  pus  approaches  the  rectal 
surface. 

An  abscess  may  form  in  the  neighbourhood  of  the  urethra,  or 
there  may  be  numerous  small  points  of  suppuration  scattered 
throughout  the  prostate,  and  no  sensation  of  softening  is  detected 
with  the  finger. 

Course  and  prognosis. — 1-  In  a  large  proportion  of  cases 
the  abscess,  if  left  alone,  ruptures  into  the  urethra,  either  spon- 
taneously, or  after  the  passage  of  a  catheter  for  retention  of  urine, 
or  after  rectal  examination.  A  quantity  of  pus  appears  in  the 
urine,  the  temperature  falls,  the  symptoms  subside ;  the  pros- 
tate diminishes  in  size  and  is  much  softer.  The  inflammation 
may  now  gradually  subside.  Recurrence  of  the  symptoms  may, 
however,  ensue  from  incomplete  drainage  and  refilling  of  the 
abscess  cavity. 

The  persistence  of  such  a  cavity  may  later  lead  to  the  forma- 
tion of  an  intraprostatic  calculus,  lime  salts  being  deposited  in 
this  paraurethral  pouch. 

2.  The  abscess  may  travel  downwards  to  the  perineum,  where 
it  appears  as  a  tender  swelling  immediately  behind  the  bulb,  and 
then  passes  forwards  in  the  perineum  to  the  scrotum.  Rectal 
examination  shows  the  pouch  below  the  prostate  filled  up  with 
an  inflammatory  mass  continuous  with  the  gland. 

3.  The  abscess  ruptures  into  the  rectum.  Pus  and  blood 
appear  in  the  stools,  but  may  be  overlooked.  The  track  is  felt 
as  a  firm  button  in  the  rectal  wall.  Healing  usually  follows,  but 
a  fistula  may  form  between  the  rectum  and  the  urethra. 

Treatment. — The  abscess  should  be  opened  and  drained  by 
the  perineal  route.     The  curved  prerectal  transverse  incision  of 


680  THE   PROSTATE  [chap. 

Zuckerkandl  is  employed,  the  posterior  surface  of  the  prostate 
exposed,  and  the  rectum  displaced  backwards.  There  is  danger 
of  wounding  the  rectum  unless  the  dissection  is  carefully  carried 
out.  The  abscess  is  opened  by  a  vertical  incision  through  the 
sheath  of  the  prostate,  and  a  large  rubber  drain  introduced  and 
retained  for  a  week,  after  which  it  is  removed  and  a  gauze  drain 
substituted. 

CHEONIC  PROSTATITIS 

Chronic  prostatitis  occurs  most  frequently  between  the  ages 
of  20  and  40,  and  may  persist  after  an  attack  of  acute  prostatitis, 
but  more  often  it  commences  insidiously  and  gives  rise  to  slight 
symptoms  in  its  early  stage. 

Etiology, — Stricture  is  frequently  present ;  chronic  urethritis, 
cystitis,  and  pyelonephritis  are  concomitant  if  not  causative  in- 
flammations. Masturbation  and  sexual  excess  are  also  believed 
to  cause  prostatitis,  and  some  authorities  hold  that  it  may  follow 
bicycling. 

Pathology. — In  the  slightest  form  the  glands  and  ducts  show 
proliferation  and  desquamation  of  epithelium,  and  the  lumen  is 
filled  with  epithelium  and  leucocytes.  At  a  later  stage  there  is 
periglandular  infiltration  with  round  cells.  Sclerosis  of  the  stroma 
may  take  place,  and  the  gland  is  firmer ;  and  later  there  is 
contraction,  either  destroying  the  gland  tubules  by  pressure  or 
causing  dilatation  from  obstruction.  Rarely  small  points  of 
suppuration  are  scattered  throughout  the  prostate. 

In  most  cases  the  inflammation  is  postgonorrhoeal,  but  there 
may  be  an  interval  of  several  years  between  the  acute  attack  of 
gonorrhoea  and  the  development  of  symptoms  of  chronic  pros- 
tatitis. It  occurs  in  35  per  cent,  of  cases  of  gonorrhoea.  Notthaft 
holds  that  the  gonococcus  does  not  survive  longer  than  three 
years,  and  it  frequently  disappears  long  before.  It  is  followed  by 
secondary  bacteria.  Young  found  that  bacteria  were  present  in 
only  6  out  of  19  cases  of  chronic  prostatitis.  This  author  believes 
that  multiple  infection  is  not  uncommon. 

Symptoms. — These  may  be  so  sHght  as  to  be  overlooked,  or 
they  may  be  combined  with  those  of  posterior  urethritis  and  be 
indistinguishable  from  them.  It  must  be  remembered  also  that 
widespread  urinary  infection  may  be  present,  with  symptoms  of 
pyelonephritis,  pyelitis,  ureteritis,  cystitis. 

The  symptoms  present  great  variety,  and  are  conveniently 
grouped  as  urinary,  nervous,  and  sexual. 

1.  Urinary  symptoms. — Increased  frequency  of  micturition 
and  scalding  or  smarting  during  the  act  are  the  most  common 


Liv]       CHRONIC  PROSTATITIS:   SYMPTOMS       681 

urinary  symptoms.  The  increased  frequency  occurs  during  the 
day,  and  in  severe  cases  at  night  also.  It  is  capricious,  varying 
from  day  to  day  and  at  diiierent  hours  of  the  day.  The  desire 
to  micturate  continues  after  the  bladder  is  empty,  and  there  may 
be  strangury.  Urgent  micturition  may  also  be  noted.  Difficult 
micturition  is  frequently  present,  and  occasionally  an  attack  of 
complete  retention.  Residual  urine  is  said  to  be  present  in  some 
cases. 

2.  Nervous  symptoms. — Aching  pain  is  characteristic.  It 
may  be  constantly  present,  or  irregular  in  its  incidence,  being 
present  for  some  part  of  a  day  or  for  some  days,  and  absent  for 
varying  periods.  It  may  be  increased  on  movement  and  exercise, 
or  on  sitting,  and  sometimes  on  rising  from  the  recumbent  position. 
The  pain  is  felt  in  the  perineum,  along  the  urethra  to  the  end  of 
the  penis,  in  one  or  both  testicles,  in  the  groins  or  hips,  or  at  the 
base  of  the  sacrum.  In  old-standing  cases  it  may  be  felt  in  regions 
distant  from  the  prostate — namely,  in  the  arms,  shoulders,  neck, 
and  thighs.  Pain  on  defsecation  and  during  coitus  is  frequently 
present.  Neurasthenia  develops  in  a  considerable  proportion  of 
these  cases. 

3.  Sexual  symptoms — ^Nocturnal  emissions  maybe  frequent, 
and  there  is  loss  of  sexual  appetite.  Prostatorrhoea  is  present  in  a 
small  percentage  of  cases  ;  this  consists  in  the  escape  of  prostatic 
fluid  during  defsecation  or  at  the  end  of  micturition,  or  even  on 
exertion.  The  normal  prostatic  secretion  is  a  milky  fluid,  alkaline 
in  reaction  or  amphoteric  (Young),  and  contains  lecithin  granules, 
amyloid  bodies,  and  isolated  epithelial  cells.  In  chronic  prostatitis 
the  secretion  is  thick,  yellow,  alkaline,  and  contains  granules  and 
flakes.  The  microscope  shows  columnar  cells,  single  or  clumped 
together,  with  numerous  leucocytes,  and  a  few  red  blood-corpuscles 
and  amyloid  bodies,  lecithin  granules,  and  granular  phosphates. 
On  the  addition  of  a  drop  of  ammonium  phosphate  (1  per  cent.) 
large  numbers  of  Bottcher  crystals  appear.  The  excess  of  epithe- 
lial cells  and  the  presence  of  leucocytes  are  characteristic  of  chronic 
prostatitis.  According  to  Goldberg  there  is  a  diminution  in  the 
lecithin  in  prostatitis.  The  urine  frequently  shows  bacilluria, 
which  may  be  intermittent  or  constant.  When  cystitis  or  pyelo- 
nephritis is  present  the  urine  has  the  characteristics  observed  in 
these  diseases. 

In  slight  chronic  prostatitis  the  terminal  portion  of  the  urine  is 
cloudy,  with  a  little  mucus  and  a  trace  of  pus,  and  contains  comma- 
shreds,  small  curved  flakes  formed  in  the  ducts  of  the  prostate. 

A  shght  albuminuria  is  present  in  many  cases,  due  to  the  pre- 
sence of  prostatic  secretion  in  the  urine.     Terminal  phosphaturia 


682  THE   PROSTATE  [chap. 

is  also  observed,  the  last  portion  of  the  urine  containing  a  cloud 
of  phosphates. 

On  rectal  examination  no  change  in  size,  consistence,  or  sensi- 
bility is  detected  in  shght  cases.  When  more  extensive  changes 
are  present  the  prostate  is  slightly  tender  and  the  consistence 
firm.  This  change  may  extend  throughout  the  gland,  or  one  lobe 
may  be  firmer  than  the  other,  or  again  the  gland  may  be  firm  act 
one  part  and  elastic  at  another.  The  firm  area  may  be  at  the 
periphery.  The  gland  may  be  fixed,  and  in  the  later  stages  is 
frequently  diminished  in  size,  and  may  be  completely  atrophic. 
The  secretion  of  the  prostate  should  be  expressed  by  massage  and 
examined.     It  has  the  characters  already  described. 

The  bacteriology  is  similar  to  that  of  acute  prostatitis.  In 
some  cases  no  bacteria  are  found,  but  it  has  been  shown  (Jungano) 
that  anaerobic  bacteria  are  present  in  all  these  cases. 

Diag^nosis. — Prostatic  fluid  must  be  distinguished  from  that 
derived  from  Cowper's  glands,  which  may  be  in  excess  (urethror- 
rhoea).     The  latter  is  clear,  viscid,  and  glycerine-like. 

Schlagintweit  introduced  the  following  macroscopic  method 
of  distinguishing  between  prostatic  fluid,  seminal-vesicle  fluid,  and 
pus.  The  fluid  is  allowed  to  drop  into  a  specimen-glass  of  water. 
Normal  prostatic  fluid  disseminates  and  gives  an  opalescent  appear- 
ance to  the  water,  pus  sinks  to  the  bottom,  and  the  seminal- vesicle 
fluid  floats  or  hangs  in  the  water  and  becomes  opaque. 

The  microscope  will  distinguish  between  spermatic  and  pros- 
tatic fluid.  In  order  to  obtain  the  prostatic  fluid  for  examination 
the  urethra  and  bladder  should  first  be  washed  with  saline  solu- 
tion and  then  several  ounces  of  the  fluid  left  in  the  bladder.  The 
patient  is  now  placed  in  the  knee-elbow  position  and  the  prostate 
gland  is  massaged  from  the  rectum  and  the  patient  directed  to  pass 
the  fluid  from  his  bladder.     This  is  centrifugahzed  and  examined. 

On  rectal  examination  tuberculous  disease  and  chronic  pros- 
tatitis must  be  differentiated.  In  tuberculous  disease  the  nodule 
is  usually  solitary,  and  it  is  harder  and  more  sharply  defined. 
There  are  frequently  tuberculous  lesions  of  the  seminal  vesicles 
and  epididymes,  in  the  urinary  tract,  or  elsewhere  in  the  body. 
An  examination  of  the  expressed  prostatic  fiuid  for  the  tubercle 
bacillus  should  be  made  in  doubtful  cases. 

Malignant  disease  of  the  prostate  in  its  early  stage  may  resemble 
chronic  prostatitis.  The  nodule  of  malignant  growth  is  harder 
and  more  sharply  defined,  and  the  symptoms  at  this  stage  are 
usually  confined  to  slight  difficulty  in  micturition  without  changes 
in  the  urine  and  without  the  neurasthenic  symptoms  which 
characterize  chronic  prostatitis. 


Liv]     CHRONIC   PROSTATITIS:  TREATMENT       683 

In  the  more  advanced  stage  of  carcinoma  there  is  no  difficulty 
in  recognizing  the  stony,  hard,  nodular,  fixed,  insensitive  prostate 
as  malignant. 

Prognosis. — The  removal  of  an  exciting  cause  such  as  stric- 
ture may  be  followed  by  resolution  of  the  prostatitis.  Usually, 
however,  chronic  prostatitis  persists  for  many  years,  either  in  a 
latent  form  with  recurrent  exacerbations,  or  with  little  or  no 
improvement.  Cases  associated  with  bacilluria  are  especially 
resistant  to  treatment. 

Epididymitis  is  a  frequent  complication,  and  may  follow  too 
energetic  treatment,  or  sexual  excess,  or  exposure  to  cold.  Atrophy 
of  the  prostate  may  eventually  ensue,  and  it  is  said  that  hyper- 
trophy may  also  result  from  this  cause. 

Treatment. — General  tonic  treatment  is  indicated,  with  open- 
air  exercise.  Horse-riding  and  bicycling  should  be  avoided. 
Ergot  and  iodide  of  potash  should  be  given.  The  bowels  should 
be  carefully  regulated.     If  a  stricture  is  present  it  should  be  treated. 

The  regular  passage  of  large  metal  instruments,  even  when 
there  is  no  narrowing  of  the  canal,  assists  to  expel  the  prostatic 
discharge  by  stretching  the  wall  of  the  urethra.  Large  instruments 
should  be  used  (Nos.  14-16  to  Nos.  16-18),  meatotomy  being  per- 
formed, if  necessary,  to  enable  the  surgeon  to  pass  the  instruments. 
Kollmann's  prostatic  urethral  dilator  is  useful  for  this  purpose  ; 
the  dilatation  is  carried  out  once  a  week,  commencing  with  No.  36 
and  gradually  rising  to  No.  60,  or  even  No.  70.  Simultaneous 
irrigation  of  the  urethra  with  weak  silver  nitrate  solutions  (1  in 
10,000)  should  be  carried  out ;  in  the  more  recently  constructed 
instruments  provision  is  made  for  this  purpose. 

Irrigation  may  be  combined  with  prostatic  massage  without 
dilatation.  The  prostate  is  first  massaged  from  the  rectum  with 
the  patient  in  the  knee-elbow  position,  and  then  the  patient  is 
placed  in  the  recumbent  posture  and  the  urethra  washed  by 
Janet's  method.  Large  quantities  of  weak  solution  are  used,  such 
as  silver  nitrate  1  in  10,000,  oxycyanide  of  mercury  1  in  5,000, 
permanganate  of  potash  1  in  5,000. 

Instillations  into  the  prostatic  urethra  by  means  of  a  Guyon's 
syringe  of  stronger  solutions,  such  as  silver  nitrate  1,  2,  or  3  per 
cent.,  are  sometimes  beneficial. 

Young  recommends  the  use  of  an  ointment  of  2  per  cent,  car- 
bolic acid  in  lanoHne  in  mild  cases,  or  1  per  cent,  salicylic  acid 
in  cases  with  epithelial  exfoliation.  The  ointments  are  introduced 
by  means  of  an  applicator. 

Prostatic  massage  is  the  most  important  method  of  treat- 
ment in  chronic  prostatitis.     The  patient  is  placed  in  the  knee- 


684  THE   PROSTATE  [chap,  liv 

elbow  position  on  a  couch,  and  a  rubber  glove,  well  lubricated, 
covers  the  surgeon's  hand.  The  forefinger  is  introduced  into  the 
rectum,  and  first  one  lobe  and  then  the  other  is  massaged  from 
without  inwards  to  the  mid-line,  and  finally  the  finger  is  swept 
down  the  interlobar  sulcus.  The  massage  lasts  five  minutes,  and 
is  succeeded  by  lavage  of  the  urethra  and  bladder,  and  the  treat- 
ment is  repeated  once  a  week. 

Suppositories  may  be  used  containing  ichthyol  3  gr.,  extract 
of  belladonna  J  gr.,  or  iodide  of  potash  5  gr. 

In  old-standing  cases  with  severe  pain  perineal  prostatectomy 

may  be  performed ;    it  succeeds  in  relieving  the  neuralgic  pain, 

but  there  is  a  tendency  to  recurrence  after  some  years.     The  use 

of  the  galvano-cautery  (Bottini's  method)  in  some  cases  has  been 

advocated. 

LITERATURE 

Bierhoff,  lied.  Neivs,  Oct.,  1904. 

von  Frisch,  Krankheiten  der  Prostata.     1899. 

Gardner,  ^rc^.  6en.  de  Chir.,  1910,  p.  482. 

Goldberg,  Zeits.  f.   Urol.,  1908,  p.  814. 

Lellei,  Zeits.  f.   Urol.,  1907,  p.  201. 

Notthaft,  ^rcA.  /.  Derm.  u.  Syph.,  1904. 

Schlagintweit,  Centralhl.  j.  d.Krankh.  d.  Ham-  u.  Sex.- Org.,   1901. 

Stern,  Amer.   Journ.  of  Med.  Sci.,  Aug.,  1903. 

Wickert,  St.  Petersburg,  med.  Wock.,  1909,  6. 

Wossidio,  Zeits.  f.   Urol,  1908,  p.  243. 

Young,  Geraghty,  and  Stevens,   Johns  Hopkins  Hosp.  Repts.,  1906,  xiii.  271. 

PERIPEOSTATITIS 

Acute  periprostatitis  is  secondary  to  acute  prostatitis  and 
prostatic  abscess.  In  prostatic  abscess  which  ruptures  into  the 
rectum  there  is  periprostatitis  with  adhesions  of  the  prostate  and 
rectal  wall.  The  pelvic  cellulitis  may  spread  beyond  the  neigh- 
bourhood of  the  prostate  to  the  lateral  wall  of  the  pelvis  and  sur- 
round the  rectum.  The  symptoms  are  masked  by  those  of  the 
acute  prostatitis.  The  patient  is  more  seriously  ill,  the  tempera- 
ture high  and  swinging,  and  rigors  are  frequent  and  severe.  On 
rectal  examination  the  outline  of  the  prostate  is  found  to  be 
obscured,  and  the  rectal  wall  fixed  in  an  inflammatory  mass  ante- 
riorly and  laterally.     Death  from  septicaemia  or  pygemia  may  occur. 

Treatment  consists  in  free  and  early  drainage  of  the  primary 
prostatic  abscess  and  of  the  pelvic  cellular  tissue  by  the  perineal 
route. 

Chronic  periprostatitis  follows  the  acute  form,  or  complicates 
primary  chronic  prostatitis.  The  prostate  and  seminal  vesicles 
are  replaced  by  a  smooth,  tough,  fibrous  surface  passing  laterally 
to  the  pelvic  wall.     The  treatment  is  that  of  chronic  prostatitis. 


CHAPTER  LV 
TUBERCULOSIS  OF  THE  PROSTATE 

Before  proceeding  to  describe  tuberculosis  of  the  prostate  gland 
it  is  convenient  to  make  some  remarks  in  regard  to  tuberculosis 
of  the  genital  system — namely,  the  epididymes  and  testicles,  the 
seminal  vesicles  and  vasa  deferentia,  and  the  prostate. 

Genital  tuberculosis  is  very  rare  in  children,  although  it  is 
occasionally  observed  as  tuberculosis  of  the  testicle  at  an  early 
age.  It  is  also  of  rare  occurrence  in  old  men,  and  at  this  age 
is  usually  a  recrudescence  of  some  old-standing  tuberculous 
lesion.  The  great  majority  of  cases  occur  between  the  ages  of  20 
and  50. 

A  part  of  the  genital  system,  such  as  the  epididymis,  may 
alone  be  affected  (partial  genital  tuberculosis)  ;  eventually,  how- 
ever, the  whole  genital  system  becomes  involved  (complete  genital 
tuberculosis). 

In  100  cases  I  found  the  following  distribution  : — 

Genital  system  alone  : 

Epid.id.3rmis  alone  . .  . .  . .  . ,         16 

Prostate  alone    . .  . .  . .  . .  . .  7 

Seminal  vesicle  alone   .  .  .  .  . .  . .  1 

Several  genital  organs  affected  . .  . .         26 

50 

Genital  and  urinary  systems  . .  . .  . .  . .         37 

Genital  system  and  urethra,  periurethral  abscess,  groin 

glands,  or  lungs      .  .  .  .  .  .  . .  . .  8 

Genital  and  urinary  systems  with  joints,  vertebrae,  or 

lungs  . .  .  .  . .         . .         . .         . .         . .  5 

100 
The  average  age  in  these  cases  was  25-6  years.  ''^^ 

Kocher  found  that  in  80  per  cent,  of  451  autopsies  on  cases 
of  genito -urinary  tuberculosis  there  were  pulmonary  tuberculous 
lesions. 

Tuberculosis  of  the  genital  system  is,  compared  with  urinary 
tuberculosis,  a  mild  form  of  infection.  The  onset  is  usually  in- 
sidious and  the  progress  slow.  Spread  to  all  the  genital  organs  is 
common,  but  not  infrequently  the  tuberculous  process  is  quiescent 

685 


686  THE   PROSTATE  [chap. 

at  one  part  when  the  next  is  affected.  Obsolete  tuberculous 
disease  of  the  genital  system  may  again  become  active  after  many 
years,  or  tuberculosis  of  the  urinary  system  may  develop  after 
a  similar  interval.  The  chief  danger  of  genital  tuberculosis  is 
that  it  may  become  urinary  by  infection  of  the  bladder  or  kidney. 
In  the  majority  of  cases  the  epididymis  is  the  genital  organ  first 
aSected,  and  it  is  therefore  more  frequently  found  affected  alone 
than  the  other  genital  organs.  The  infection  reaches  the  epididy- 
mis by  the  blood  stream,  and  also  by  the  vas  deferens.  The 
prostate  and  seminal  vesicles  may  be  infected  from  the  epididymis 
by  way  of  the  vas  deferens,  or  they  may  be  infected  from  the 
blood  stream  or  from  the  urethra.  In  support  of  his  view  that 
the  epididymis  is  always  affected  first  and  the  prostate  later, 
Salleron  states  that  in  51  cases  of  tuberculous  epididymitis  the 
prostate  was  only  once  affected.  On  the  other  hand,  Keyes  and 
Macfarlane  Walker  hold  that  there  is  always,  or  nearly  always, 
some  abnormal  condition  of  the  prostate  or  vesicles.  They  admit, 
however,  that  these  lesions  are  not  necessarily  tuberculous.  In 
my  statistics  quoted  above  only  tuberculous  lesions  were  included. 
These  show  that  the  epididymis  was  much  more  frequently  affected 
alone  (16  per  cent.)  than  any  of  the  other  organs. 

Etiology. — In  tuberculosis  of  the  prostate  there  is  often  a 
family  history  of  tuberculosis.  Gonorrhoeal  inflammation  is  said 
to  be  a  frequent  precursor  of  tuberculous  prostatitis,  but  genital 
tuberculosis  (including  prostatic  tubercle)  is  very  often  found  in 
patients  who  have  not  had  gonorrhoea.  I  have  only  seen  2  cases 
where  tuberculosis  of  the  prostate  appeared  to  follow  directly 
upon  an  attack  of  acute  gonorrhoeal  urethritis  and  prostatitis,  and 
in  these  cases  it  was  impossible  to  prove  that  latent  tuberculous 
nodules  had  not  previously  been  present.  There  are  cases  of  tuber- 
culosis of  the  prostate  in  which  the  onset  is  acute  and  is  accom- 
panied by  a  fairly  copious  urethral  discharge  and  symptoms  of 
posterior  urethritis.  It  is  possible  that  such  cases  have  been  mis- 
taken for  gonorrhoeal  urethritis,  and  only  in  the  subsequent  chronic 
stage  recognized  as  tuberculous.  Chronic  tuberculous  nodules  are 
not,  in  my  experience,  found  in  prostates  which  show  clinical 
evidence  of  chronic  prostatitis.  In  the  early  stage  the  prostate 
in  which  the  tuberculous  nodule  is  set  is  elastic  and  normal  to 
the  touch. 

The  prostate  was  affected  alone  in  7  of  the  100  cases  in  the 
above  table.  In  cases  where  the  genital  system  alone  was  tuber- 
culous the  prostate  was  the  solitary  focus  of  tubercle  in  14  per 
cent.,  and  in  combination  with  other  genital  organs  in  52  per- 
cent.    In   65  per  cent,   of  cases  of  prostatic  tubercle  there  was 


Lv]  TUBERCULOUS  PROSTATITIS :  SYMPTOMS  687 

urinary  tubercle  also,  and  in  18  per  cent,  of  these  the  prostate  was 
the  only  genital  organ  att'ected.  Tuberculous  disease  was  also 
noted  in  different  cases  in  the  urethra,  periurethral  tissues,  the 
groin  glands,  elbow-joints,  vertebrae,  and  lungs.  In  100  cases  of 
pulmonary  tuberculosis  Reclus  found  only  2  in  which  the  genito- 
urinary organs  were  affected. 

Pathology.  —  The  tuberculous  process  commences  in  the 
neighbourhood  of  the  acini  and  gland  ducts,  the  bacilli  lying  im- 
mediately underneath  the  epithelium.  Giant-cell  systems  form,  the 
periacinous  tissue  is  widely  infiltrated,  and  caseation  takes  place. 

There  may  be  a  number  of  discrete  nodules  or  a  single  mass. 
The  peripheral  portion  of  the  gland  is  at  first  affected,  but  the 
whole  lobe  becomes  involved.  One  lobe  may  be  affected  and 
the  other  remain  intact.  The  caseous  masses  frequently  break 
down,  and  a  large  single  cavity  or  several  intercommunicating 
pockets  replace  the  prostatic  tissue.  Rupture  most  frequently 
takes  place  into  the  urethra  by  one  or  several  openings,  or  through 
the  bladder  base  alongside  the  trigone,  a  large  irregular  opening 
resulting. 

Less  frequently  rupture  takes  place  into  the  rectum,  and 
occasionally  the  tuberculous  collection  infiltrates  the  periprostatic 
tissue  and  passes  down  along  the  urethra  into  the  perineum. 
After  rupture  into  the  urethra  the  tuberculous  process  usually 
becomes  quiescent,  and  the  lobe  of  the  prostate  fibrous  and 
shrunken.  Infection  of  the  bladder  may  take  place  by  the  urethra 
or  directly  through  the  base  of  the  organ.  After  rupture  into  the 
rectum  the  lobe  usually  shrinks.  Fistulas  may  form  when  the 
abscess  invades  the  perineum. 

In  late  cases  the  prostate  and  prostatic  urethra  are  destroyed 
and  a  cavity  communicating  with  the  bladder  is  formed.  The 
urethra  in  front  of  this  is  frequently  the  seat  of  tubercidous  stric- 
ture. The  infection  here  is  mixed,  and  secondary  phosphatic 
calculi  may  form  in  the  cavity  or  in  the  bladder. 

Symptoms. — There  may  be  complete  absence  of  symptoms, 
and  the  tuberculous  nodule  is  discovered  on  routine  examination 
of  the  rectum. 

Frequent  micturition  is  often  present ;  it  is  both  diurnal  and 
nocturnal,  and  is  little  afi'ected  by  movement. 

A  urethral  discharge  may  be  the  initial  symptom,  and  is  not 
infrequently  mistaken  for  a  gonorrhoeal  infection.  The  discharge 
is  sometimes  copious,  and  may  appear  suddenly.  Haematuria 
may  appear  at  an  early  stage,  or  it  may  indicate  the  rupture  of 
a  tuberculous  collection  into  the  urethra.  Blood  may  also  appear 
in  the  emissions. 


688  THE   PROSTATE  [chap. 

These  sjrmptoms  are,  however,  often  absent.  When  rupture 
into  the  bladder  takes  place  the  symptoms  of  cystitis  appear. 

The  urine  is  clear  in  the  early  stage,  and  no  tubercle  bacilli 
can  be  detected,  but  when  rupture  into  the  urethra  or  bladder 
has  occurred  the  urine  contains  pus,  tuberculous  bacilli,  and  debris, 
and  sometimes  blood.  A  mixed  infection  of  bacillus  coli,  staphylo- 
coccus, and  streptococcus  introduced  by  instruments  or  appear- 
ing spontaneously  may  be  fomid,  and  the  tubercle  bacillus  may 
only  be  discovered  after  repeated  examinations. 

In  late  cases  the  infection  is  mixed  and  the  bladder  in- 
vaded; secondary  calculi  form,  and  the  urethra  anterior  to  the 
prostate  is  narrowed  by  tuberculous  infiltration.  The  desire  to 
micturate  is  constant,  and  there  is  pain  and  burning  along  the 
urethra,  with  great  straining,  and  the  discharge  of  a  few  drops  of 
urine  at  each  attempt.  The  patient  is  robbed  of  his  sleep  and 
rapidly  loses  flesh.  The  temperature  may  be  raised  one  or  two 
points. 

On  rectal  examination  the  prostate  is  tender,  and  one  or  more 
tuberculous  nodules  can  be  felt.  The  nodule  is  hard  and  well 
defined,  and  is  usually  situated  at  the  upper  and  outer  angle,  or 
at  the  outer  and  lower  part  of  the  gland.  It  is  more  sharply 
defined  and  harder  than  a  patch  of  chronic  non-tuberculous 
prostatitis,  and  is  set  or  buried  in  a  prostate  of  normal  consist- 
ence, whereas  chronic  non-tuberculous  prostatitis  gives  rise  to  ill- 
defined  firm  areas  in  a  prostate  of  tough  consistence. 

One  or  both  lobes  may  be  affected.  When  a  tuberculous 
collection  has  ruptured  into  the  urethra  a  hollow  is  felt  in  its 
place,  and  the  remaining  lobe  is  unduly  prominent.  A  small 
button  of  induration  is  felt  in  the  rectal  wall  where  rupture  into 
the  rectum  has  taken  place. 

The  passage  of  instruments  through  the  prostatic  urethra  may 
be  difficult,  owing  to  narrowing  and  distortion  of  the  canal.  Cys- 
toscopy frequently  shows  a  prominent  congested  and  sometimes 
oedematous  area  on  the  upper  surface  of  the  prostate.  After 
rupture  into  the  bladder  an  irregular  cavity  is  seen  alongside  the 
trigone,  and  caseous  tubercles  may  be  observed  around  it. 

Prognosis. — If  septic  complications  are  not  superadded  and 
urinary  and  pulmonary  tuberculosis  are  absent  there  is  a  ten- 
dency to  spontaneous  recovery.  When  rupture  into  the  bladder 
has  occurred,  or  fistulse  have  formed  in  the  perineum  and  else- 
where, the  prognosis  is  less  favourable,  but  recovery  under  treat- 
ment may  still  take  place.  Recrudescence  of  the  tuberculous 
process  may  occur  many  years  after  it  is  apparently,  obsolete, 

A  fatal  result  is  usually  due  to  urinary  tuberculosis  and  sepsis. 


Lv]  TUBERCULOUS   PROSTATITIS  689 

or  to  tuberculous  disease  elsewhere.  General  tuberculosis  is  rare. 
Simmonds  found  that  tuberculous  meningitis  occurred  in  30  per 
cent,  of  60  cases,  but  this  complication  was  rare  in  my  cases. 

Treatment. — The  passage  of  instruments  through  the  urethra 
should,  as  far  as  possible,  be  avoided ;  and  the  instillation  of 
medicaments  into  the  prostatic  urethra  is  harmful. 

Suppositories  of  belladonna  I  gr.,  ichthyol  2  gr.,  lupulin  4  gr., 
or  other  drugs  may  be  given  to  soothe  the  irritation  and  relieve 
congestion,  but  they  have  little  effect  on  the  course  of  the  disease. 
The  injection  of  tubercuUn  (T.R.)  is  the  most  efficacious  method 
of  treatment.  The  dosage  should  commence  at  -j,ViT  nig.,  and 
the  injections  are  given  once  a  week  and  gradually  raised  to 
KfVo  or  TTiMi  nag.  A  reaction,  shown  by  headache,  malaise,  and 
increase  in  the  local  symptoms,  should  be  avoided.  The  treat- 
ment should  be  continued  for  many  months,  or  even  several 
years,  either  continuously  or  in  courses  of  three  or  four  months. 
The  patient  should  at  the  same  time  be  placed  under  the  best 
possible  hygienic  conditions,  and  should  have  a  free,  nourishing 
diet  and  take  cod-liver  oil  and  malt.  In  my  hands  this  treatment 
has  given  very  successful  results,  and  has  entirely  superseded 
operative  measures. 

Operative  treatment  consists  in  the  exposure  of  the  prostate 
by  Zuckerkandl's  transverse  prerectal  incision,  the  tuberculous 
focus  being  then  exposed  by  incision  of  the  prostatic  sheath, 
thoroughly  scraped,  and  packed  with  iodoform  gauze  or  gauze 
soaked  in  iodine  solution. 

Prostatectomy  may  be  performed  instead  of  scraping.  In 
this  case  the  prostatic  urethra  should  not  be  opened. 

After  these  operations  a  fistula  lined  with  tuberculous  granu- 
lation tissue  frequently  persists.  For  this  the  treatment  should 
consist  in  scraping,  applications  of  iodine  or  of  bismuth  paste 
(vaseline  20,  paraffin  10,  lanoUne  10,  bismuth  subnitrate  10),  and 
the  administration  of  tuberculin. 

Where  a  mixed  infection  is  present,  vaccines  should  be  com- 
bined with  tuberculin  treatment. 

In  late  cases  where  the  prostate  is  entirely  destroyed  and  the 
bladder  infected,  permanent  suprapubic  drainage  gives  great  relief. 

LITERATURE 

von  Frisch,   Kranhheiten  der  Prostata.     1899. 

Guisy,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1906,  p.   1409. 

Halla  et  Motz,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1903,  p.  481. 

Hildebrand,  Zeits.  f.   Urol,  1907,  p.  827. 

Simmonds,  Miinch.  med.  Woch.,  1901,  p.  743. 

Walker,  Macfarlane,  Lancet,  1913,  i.  435. 

Walker,  Thomson,  Pract.,  May,  1908. 


CHAPTER  LVI 
SIMPLE  ENLARGEMENT  OF  THE  PROSTATE 

Enlaegement  of  the  prostate  is  a  disease  of  advanced  life,  the 
frequency  of  which  has  been  stated  at  35  per  cent,  of  men  over 
60  years. 

Cause  and  nature  of  the  enlargement. — At  the  present 
time  opinion  is  unsettled  as  to  the  cause  and  nature  of  the  change 
in  the  prostate.  A  number  of  theories  have  been  advanced,  the 
more  important  of  which  will  be  stated. 

1.  Adenoma. — The  changes  in  the  gland  conform  very  closely 
to  those  found  in  adenoma  of  other  organs,  such  as  the  breast, 
and  carcinoma  occasionally  develops  in  the  enlarged  prostate. 
Recently  this  view  as  to  the  nature  of  the  enlargement  has  been 
pushed  into  the  background  by  theories  advanced  to  explain  the 
origin  of  the  change.  Whatever  the  origin  may  be,  simple  enlarge- 
ment of  the  prostate  resembles  in  its  gross  and  histological  charac- 
ters an  adenoma  with  a  varying  amount  of  cystic  formation. 

2.  Hypertrophy. — Occasionally  there  is  a  uniform  increase 
in  the  gland  tubules,  resembling  those  of  the  normal  gland.  This 
might  be  looked  upon  as  a  true  hypertrophy,  but  in  the  great 
majority  of  cases  there  are  changes  such  as  dilatation  of  the  gland 
tubules,  subdivision  into  nodules,  etc.,  which  show  that  the  pro- 
cess is  more  than  a  simple  hypertrophy. 

The  so-called  hypertrophy  has  been  said  by  White,  Macewen, 
and  others  to  be  secondary  to  changes  which  occur  in  the  testicle 
in  old  age. 

3.  Arterio-sclerosis. — Based  upon  researches  by  Launois, 
Guyon  and  others  have  held  the  view  that  enlargement  of  the 
prostate  is  a  part  of  arterio-sclerotic  changes  which  take  place 
in  the  entire  urinary  apparatus  (kidneys,  ureters,  bladder).  There 
is  interstitial  nephritis,  sclerosis  of  the  bladder  wall,  with  destruc- 
tion of  the  muscular  tissue  and  endoperiarteritis  in  these  organs. 
According  to  Guyon,  this  constitutes  the  condition  of  "  prostatis- 
mus,"  which  is  usually,  but  not  always,  combined  with  enlarge- 
ment of  the  prostate.  Casper  has  shown  that  although  arterio- 
sclerosis and  hypertrophy  of  the  prostate  may  be  present  in  the 

690 


CHAP.  Lvi]    ENLARGED  PROSTATE  :  ETIOLOGY     691 

same  individual,  hypertrophy  frequently  occurs  without  any  change 
in  the  blood-vessels  of  the  prostate  or  bladder  ;  while  Motz  found 
that  of  31  cases  of  hypertrophy  of  the  prostate  the  blood-vessels 
were  normal  in  16,  simple  congestion  without  changes  in  the  vessel 
walls  was  present  in  6,  and  arterio-sclerosis  occurred  in  9.  The 
complete  restoration  of  the  function  of  the  bladder  after  removal 
of  the  prostate  in  cases  where  the  patient  had  been  dependent 
upon  the  catheter  for  many  years  has  demonstrated  that  no  such 
destructive  changes  take  place  in  the  bladder.  This  view  must 
therefore  be  abandoned. 

4.  Inflammatory  changes. — Recently  Ciechanowski  has  re- 
vived and  developed  the  theory  that  the  enlargement  is  due 
to  inflammatory  changes.  According  to  this  observer,  the  in- 
flammatory process  exists  for  years  with  slight  or  no  appreciable 
symptoms.  There  is  a  chronic  inflammation  affecting  the  stroma 
of  the  gland.  If  this  involves  the  portion  of  the  gland  imme- 
diately adjacent  to  the  urethra  and  surrounds  the  principal  gland 
ducts  of  the  prostate,  the  lumen  of  these  is  narrowed  and  the 
secretion  collects  in  the  acini  of  the  gland  and  dilates  them.  At 
the  same  time  there  is  .proliferation  and  desquamation  of  the  epi- 
thelium. The  enlargement  of  the  gland  is  almost  entirely  due  to 
dilatation  of  the  gland  tubules.  To  this  Ciechanowski  adds  that 
if  the  inflammation  principally  aflects  the  peripheral  portion  of 
the  gland  the  acini  are  compressed  instead  of  being  obstructed, 
and  atrophy  of  the  prostate  takes  place. 

The  great  frequency  of  gonorrhoea  as  a  cause  of  chronic  prosta- 
titis suggests  that  this  may  be  the  origin  of  the  inflammatory 
changes  ;  but  Ciechanowski  regards  this  hypothesis  as  still  un- 
proved. Rovsing  found  that  60  per  cent,  of  his  cases  of  enlarge- 
ment of  the  prostate  had  never  had  gonorrhoea,  and  showed  no 
trace  of  urethritis. 

5.  Motz  and  Perearnau  have  recently  advanced  the  view  that 
the  so-called  hypertrophy  of  the  prostate  is  due  to  changes  in 
the  urethral  glands  of  the  prostatic  urethra,  and  that  the  true 
prostatic  tubules  do  not  take  part  in  the  formation  of  the  tumour, 
but  are  crushed  aside  and  atrophy.  The  arguments  in  favour  of 
this  theory  are  ably  marshalled  by  Marion,  but  are  unconvincing. 

Age-Incidence. — The  symptoms  of  enlargement  of  the  prostate 
commence  after  the  age  of  50,  usually  between  the  ages  of  55  and 
60.  The  change  undoubtedly  begins  earlier,  but  the  statement 
of  Burckhardt  that  13  per  cent,  of  cases  commence  between  36 
and  40,  and  25  per  cent,  between  40  and  50,  is  entirely  contrary 
to  my  experience.  Von  Frisch  has  never  seen  true  hypertrophy  of 
the  prostate  before  50,  and  holds  that  the  cases  recorded  at  earlier 


692  THE   PROSTATE  [chap. 

ages  than  this  are  cases  of  chronic  prostatitis.  It  is  certainly 
exceptional  to  find  true  enlargement  of  the  prostate  before  the 
age  of  50,  but  cases  are  occasionally  observed.  I  have  removed 
a  prostate  weighing  1|  oz.,  with  a  well-developed  intravesical  pro- 
jection and  the  typical  structure  of  the  enlarged  prostate,  from  a 
man  aged  42.  The  average  age  of  112  patients  on  whom  I  per- 
formed suprapubic  prostatectomy  was  66  years. 

In  India,  according  to  Freyer,  the  symptoms  of  enlargement 
of  the  prostate  appear  as  early  as  45  years.  In  tropical  climates 
puberty  occurs  early,  and  senile  changes  set  in  some  years  before 
they  commence  in  a  temperate  climate. 

Pathologfical  anatomy. — The  average  weight  of  the  prostate 
is  about  4^  drachms,  but  the  organ  varies  very  greatly  in  weight 
and  size  in  normal  individuals,  so  that  the  commencement  of 
enlargement  cannot  be  estimated  by  relation  to  this  standard. 
Enucleated  enlarged  prostates  vary  in  weight  from  a  few  drachms 
to  14  oz. ;  the  most  frequent  size  is  from  1^  to  3  oz.  A  pros- 
tate of  6  or  8  oz.  forms  a  large  mass.  In  slight  enlargement  the 
earliest  changes  are  the  protrusion  of  a  portion  of  the  gland  into 
the  bladder  and  the  macroscopical  and  microscopical  changes  seen 
on  section. 

Both  lobes  are  usually  enlarged  to  an  equal  degree,  but  one 
may  be  larger  than  the  other,  and  rarely  the  enlargement  appears 
to  be  confined  to  one  lobe.  In  all  such  cases  that  I  have  examined, 
however,  the  apparently  normal  lobe  shows  changes  on  section 
and  microscopical  examination  which  correspond  exactly  to  those 
in  the  large  lobe. 

The  enlarging  prostate  expands  its  sheath,  and,  as  it  passes 
backwards  beneath  the  base  of  the  bladder,  strips  the  seminal 
vesicles  from  the  bladder  until  they  come  to  lie  behind  the  upper 
part  of  the  enlarged  prostate  instead  of  above  the  gland. 

I  pointed  out  in  1904  that  the  enlargement  of  the  gland  was 
in  the  majority  of  cases  confined  to  the  portion  lying  above  the 
level  of  the  ejaculatory.  ducts  and  the  verumontanum,  and  that 
the  increased  space  required  for  the  enlarged  prostate  is  obtained 
almost  entirely  at  the  expense  of  the  structures  abutting  upon 
the  upper  portion  of  the  gland,  little  or  no  change  occurring  at 
the  lower  part.  The  verumontanum  and  ejaculatory  ducts 
remain  fixed.  It  is  not  only  the  upper  median  portion  of  the 
gland  (so-called  middle  lobe)  that  enlarges,  but  the  entire  upper 
portion.  Some  years  later  (1911)  this  point  was  again  raised  by 
Tandler  and  Zuckerkandl,  who  hold  that  the  lower  part  of  the 
gland  is  crushed  and  flattened  and  takes  no  part  in  the  tumour 
which  is  removed  by  operation.    In  a  few  prostates  I  found  that 


LVl] 


ENLARGED  PROSTATE:  ANATOMY 


693 


the  glandular  substance  below  the  ejaculatory  ducts  and  behind 
the  urethra  was  the  seat  of  marked  enlargement,  and  in  such  cases 
the  ejaculatory  ducts  and  seminal  vesicles  retain  their  normal 
relations  to  the  bladder  wall  and  to  the  prostate  as  a  whole. 

A  second  direction  in  which  the  enlarged  prostate  expands  is 
into  the  bladder.  (Fig.  211.)  The  upward-growing  prostate  insinu- 
ates itself  within  the  circle  of  the  sphincter  vesicae,  which  becomes 
more  and  more  dilated  as  the  projection  becomes  larger.  This  up- 
ward-projecting portion  of  the  prostate  is  still  covered  by  the  sheet 


3  4 

Fig.  211. — Diagrams  illustrating  enlarging  prostate. 

1,  Antero-posterior  section  of  normal  prostate  and  bladder  base.  2,  Enlargement  of  prostate 
backwards  beneath  base  of  bladder.  3,  Enlargement  of  prostate  through  sphincter.  4,  Intra- 
vesical enlargement  of  prostate. — A,  Bladder.  B,  B,  Prostatic  urethra,  C,  Vesical  mucous 
membrane.  D,  Internal  longitudinal  layer  of  bladder  muscle.  E,  E,  Trigone  muscle  and 
sphincter.  F,  Outer  longitudinal  layer  of  bladder  muscle.  G,  Seminal  vesicle.  H,  Ejaculatory 
duct.  K,  K,  K,  Prostate.  L,  Prostate  pushing  seminal  vesicle  backwards.  M,  N,  Prostate 
projecting  into  bladder.     O,  Groove  in  enlarged  prostate  from  pressure  of  sphincter. 

of  longitudinal  muscle  fibres  which  forms  the  superficial  layer  of 
the  trigone  and  passes  into  the  internal  longitudinal  layer  of  the 
urethra.  At  one  point  or  at  several  the  fibres  of  this  layer  separate 
and  allow  a  nodule  of  prostatic  tissue  to  appear  immediately  under 
the  bladder  mucous  membrane.  In  grooves  on  each  side  of  this 
nodule,  or  between  each  of  several  intravesical  nodules,  are  found 
these  longitudinal  muscular  bundles  crowded  together  in  strong 
bands. 


694  THE  PROSTATE  [chap. 

The  upper  surface  of  the  prostate  is  in  the  form  of  a  horse- 
shoe around  the  back  and  sides  of  the  urethra,  and  often  pro- 
trudes into  the  bladder  in  this  form,  the  "  collar -like  "  intra- 
vesical projection.  Another  form  of  intravesical  projection  is 
the  so-called  median  lobe.  I  have  explained  the  formation  of 
this  lobe  as  follows  :  The  longitudinal  muscle  of  the  ureters  passes 
into  the  trigone,  forming  two  strong  bands  which  converge  and 
pass  over  the  posterior  lip  of  the  urethral  orifice  to  join  the  internal 
longitudinal  layer  of  urethral  muscle.  The  enlarged  prostate, 
pressing  upwards,  pushes  in  between  these  two  bands  and  forms  a 
nodule  in  the  middle  hue  posteriorly,  which  may  become  peduncu- 
lated from  the  pressure  at  its  base.  These  bands  of  longitudinal 
muscle  are  readily  recognized  in  the  grooves  on  each  side  of  the 
median  lobe  of  the  prostate  after  removal. 

In  54  enucleated  prostates  the  following  was  the  character  of 
the  intravesical  projection  :  Median  lobe  alone,  9 ;  median  and 
lateral  lobes  as  a  collar  or  distinct,  18 ;  both  lateral  lobes,  15  ; 
one  lateral  lobe,  12. 

The  intravesical  median  lobe  in  the  majority  of  cases  is  an 
offshoot  from  one  of  the  lateral  lobes,  but  in  a  few  it  is  found  to 
be  distinctly  separated  from  ihese  and  to  arise  from  the  median 
portion  of  the  prostate,  which  lies  above  the  ejaculatory  ducts. 

Changes  in  the  urethra. — The  prostatic  urethra  is  elongated, 
and  may  be  as  much  as  twice  the  normal  length.  A  catheter 
passes  in  12  or  15  in.  before  the  eye  reaches  the  bladder.  The 
elongation  affects  that  portion  of  the  urethra  which  lies  between 
the  bladder  and  the  verumontanum,  and  hardly  at  all  the  part 
in  front  of  this.  The  canal  is  compressed  laterally  and  elongated 
from  before  backwards,  so  that  it  becomes  a  median  antero-pos- 
terior  slit.  The  anterior  wall  remains  vertical,  but  the  posterior 
wall  sinks  backwards  at  the  level  of  the  verumontanum,  so  that 
the  part  above  this  point  forms  an  acute  angle  with  that  below 
it.  This  is  probably  due  to  dragging  on  the  verumontanum  by 
the  ejaculatory  ducts  and  the  surrounding  bands  of  tissue,  due  to 
the  seminal  vesicles  being  displaced  backwards. 

Lateral  distortion  of  the  urethra  is  caused  by  enlargement 
of  one  or  other  lobe,  and  a  median  lobe  produces  a  Y-shaped  canal 
or  directs  the  lumen  forwards. 

At  the  internal  meatus  the  intravesical  projection  of  the 
prostate  drags  the  sensitive  prostatic  mucous  membrane  up  into 
the  bladder.  The  orifice  may  be  crescentic,  Y-shaped,  irregular, 
or  trumpet-shaped,  according  to  the  shape  of  the  intravesical 
projection. 

On  section  of  the  enlarged  prostate  a  milky  juice  exudes  from 


Lvi]       ENLARGED   PROSTATE:   STRUCTURE       695 

the  surface.  On  each  side  of  the  long  antero-posterior  slit  which 
represents  the  urethra  is  a  large  yellowish-white  mass  in  which 
are  embedded  smaller  rounded  masses,  each  surrounded  by  a 
capsule.     These  contain  numerous  small  cysts.     (Fig.  212.) 

Microscopically,  the  enlarged  prostate  shows  closely-set  gland 
tubules,  some  of  them  small  and  normal  in  appearance,  but  the 
majority  dilated  and  branched.  (Fig.  213.)  The  dilatation  may 
be  extreme,  and  numerous  small  cysts  are  produced.  The  epithe- 
lium in  many  of  the  dilated  tubules  is  heaped  up  into  masses.    The 


Fig.  212. — Transverse  section  of  prostate  removed  by 
suprapubic  prostatectomy. 

A,  Prostatic  urethra.  B,  Veruraontanum.  C,  D,  Right  and  left  lobes.  E,  Small  cyst  in 
adenomatous    nodule.       F,    G,     Capsule.       H,     Anterior    commissure.       K,     Splitting    due    to 

manipulation. 

dilated  gland  spaces  contain  desquamated  epithelium,  granular 
material,  and  amyloid  bodies.  In  some  enlarged  prostates  the 
glandular  elements  are  less  abundant,  the  stroma  more  prominent, 
and  the  consistence  firmer.  Inflammatory  changes  in  the  stroma 
are  usually  absent,  but  perivascular  round-cell  infiltration  may 
be  observed.  A  nodule  of  circularly  disposed  non-striped  muscle 
fibres  (myoma)  may  be  fomid  in  the  substance  of  a  glandular 
enlargement. 

Secondary  changes  in  the  urinary  organs  take  place, 
ancTaxe  due  to  obstruction  and  infection.  The  projection  of 
the  prostate   into   the   bladder   raises  up  the  base  of   the  bladder 


696  THE  PROSTATE  [chap. 

around  the  urethral  orifice,  and  behind  this  there  is  a  hollow,  the 
postprostatic  pouch,  in  which  calculi  may  Be  lodged.  The  HIadder 
shows  hypertrophy  and  later  sacculation  between  the  thick  tra- 
beculse,  or  there  may  be  a  single  or  several  larger  diverticula. 

The  ureteric  orifices  usually  remain  intact  and  are  not  dilated. 
There  is^jlight  dilatation  of  the  renal  pelvis  and  kidney,  and  chronic 
interstitial  nephritis  develops.  When  sepsis  is  superadded,  by 
the  passage  of  a  catheter  or  other  means,  cystitis  and  secondary 


^,:^>r'^---  ''r-^y v^-^":^^  '^  • 


Fig.  213, — Section  of  enlarged  prostate  removed  by 
suprapubic  operation. 

At  upper   part   is   capsule    containing   blood-vessels ;    at  lower   part   are   dilated  gland  tubules 
with  proliferation  of  epithelium. 

stone  formation  follow.     Ascending  pyelonephritis  develops,   and 

r^y  be  acute  or  chronic.  »^«--'-— 

n^ 'Symptoms.— Enlargement  of  the  prostate  may  be  latent  for 
several  years  until  it  has  reached  a  large  size,  and  then  complete 
retention  may  occur.  Usually,  however,  symptoms  commence 
gradually,  the  first  being  those  of  vesical  irritation.  Later,  symp- 
toms of  increasing  obstruction  appear,  and  in  advanced  cases 
symptoms  of  renal  failure  develop.  Septic  complications  may 
supervene. 

Frequent  micturition  is  usually  the  earhest  symptom.  It 
begins  insidiously  and  increases  progressively,  and  is  both  noc- 
turnal  and   diurnal.     The  nocturnal   frequency  is   characteristic. 


Lvi]        ENLARGED   PROSTATE:   SYMPTOMS        097 

The  patient  rests  for  four  or  five  hours  during  the  first  part  of  the 
night,  is  disturbed  at  2  or  3  a.m.,  and  may  pass  water  several  times 
after  this.  If  cystitis  is  present  the  frequency  loses  this  char- 
acter. There  is  urgency  to  pass  water,  and  a  little  may  escape 
involuntarily,  but  usually,  when  the  attempt  is  made,  there  is 
delay  in  commencing  micturition. 

The  stream  lacks  force  ;  it  commences  feebly,  gradually  in- 
creases in  power,  and  falls  away  again  to  a  dribble  at  the  end  of 
the  act.  Intermittent  micturition  is  frequently  observed,  the 
pause  lasting  a  few  seconds,  or  as  long  as  a  quarter  of  an  hour. 
Micturition  may  be  best  performed  when  at  stool,  or  special  atti- 
tudes may  be  adopted  by  different  patients,  such  as  the  knee-elbow 
position,  in  order  to  facilitate  the  flow  of  urine.  The  difficulty  is 
increased  on  holding  the  water  for  some  time,  also  in  cold  weather, 
and  after  taking  alcohol. 

Ketention  of  urine  occurs  in  many  cases.  There  may  be  partial 
retention,  the  residual  urine  amounting  to  4-10  oz.,  but  the  patient 
is  able  to  micturate  and  the  bladder  is  not  distended.  Occasion- 
ally there  is  chronic  distension  of  the  bladder,  which  may  reach 
the  level  of  the  umbilicus.  The  patient  is  usually  unaware  of  the 
distension,  although  he  may  have  noticed  an  increase  in  the  girth  of 
his  abdomen.  Urine  is  passed  frequently  and  in  small  quantities 
day  and  night,  and  there  is  often  some  involuntary  dribbling  of 
urine  during  sleep.  Sudden  complete  retention  may  occur  when  a 
few  ounces  of  residual  urine  had  previously  been  present  or  none 
had  been  known  to  exist.  The  distension  of  the  bladder  is  painful, 
and  the  patient  is  usually  in  great  distress.  After  a  time  the  urine 
begins  to  dribble  away  involuntarily,  micturition  becomes  gradu- 
ally restored,  and  the  patient  returns  to  his  original  condition. 
The  attack  of  retention  may  last  an  hour  or  several  hours,  or  it 
may  be  relieved  only  by  the  passage  of  a  catheter.  Occasionally 
such  an  attack  is  followed  by  permanent  inability,  which  is  only 
cured  by  removal  of  the  prostate.  Such  an  attack  usually  follows 
exposure  to  cold  or  wet  or  dietary  indiscretions.  Acute  retention 
may  suddenly  supervene  when  no  symptoms  of  enlargement  of  the 
prostate  have  previously  been  noticed. 

Hsematuria  is  not  usually  present  apart  from  instrumental 
interference,  but  in  some  cases  it  is  the  principal  and  most  urgent 
symptom,  and  operation  may  become  necessary  on  this  account 
alone. 

Pain  is  usually  due  to  secondary  conditions.  There  are  dis- 
comfort and  burning  on  micturition,  not  amounting  to  pain. 
Suprapubic  pain  and  renal  pain  are  due  to  obstruction.  There 
may  be  pain  in  one  or  both  kidneys  on  micturition,  caused  by 


698  THE   PROSTATE  [chap. 

dilatation  of  the  ureters.  There  is  a  sensation  of  heaviness  and 
weight  in  the  perineum  and  rectum.  Sexual  irritation  is  not  in- 
frequent, and  may  be  a  very  distressing  symptom.  Constipation 
is  almost  invariably  present. 

Symptoms  due  to  secondary  conditions  may  appear.  In  reten- 
tion of  urine  there  are  suprapubic  pain,  dullness  on  percussion,  and 
a  globular  swelling. 

When  interstitial  changes  are  occurring  in  the  kidneys  the 
symptoms  of  renal  inefficiency  develop.  These  are  headache, 
burning  thirst,  especially  at  night,  dry  tongue,  loss  of  appetite, 
nausea,  a  harsh  dry  skin,  polyuria,  and  general  malaise  (p.  10). 

Haemorrhoids,  prolapse  of  the  rectum,  and  inguinal  hernia 
result  from  constant  straining  to  pass  water. 

Examination. — After  obtaining  an  account  of  the  history  and 
symptoms  the  surgeon  will  proceed  to  examine  the  patient. 

The  general  condition  in  regard  to  emaciation,  sallowness  of  the 
skin,  absence  of  sweat,  etc.,  is  noted.  The  abdomen  is  examined 
for  distension  of  the  bladder,  and  the  loins  are  palpated  to  ascertain 
if  there  is  enlargement  or  tenderness  of  the  kidneys. 

Rectal  examination  is  then  carried  out  The  patient  is 
examined  first  in  the  knee-elbow  position,  and  the  posterior  or 
rectal  surface  of  the  prostate  is  palpated.  The  size  of  the  gland 
is  found  to  be  increased.  The  gland  may  reach  a  very  large  size 
and  form  a  large  prominence  in  the  rectum,  obstructing  its  lumen. 
The  consistence  is  uniform  and  usually  elastic,  occasionally  it  is 
firm.  The  gland  is  movable,  the  surface  smooth,  and  the  outline 
well  defined.  The  median  vertical  sulcus  may  be  obliterated.  In 
some  cases  the  gland  is  found  to  be  little  enlarged  on  rectal  palpa- 
tion, the  symptoms  being  caused  by  an  intravesical  projection. 

Bimanual  palpation  is  performed  with  the  patient  lying  on 
his  back  and  his  knees  fully  flexed,  the  feet  being  firmly  planted 
on  the  couch.  The  bladder  must  be  empty.  The  right  forefinger 
is  introduced  into  the  rectum  and  the  fingers  of  the  left  hand  press 
deeply  immediately  above  the  pubic  symphysis.  Assistance  may 
be  obtained  by  placing  the  patient  in  the  Trendelenburg  position. 
A  large  prostate  can  be  felt  between  the  two  hands  and  its  mobility 
estimated. 

Examination  for  residual  urine. — The  passage  of  a  catheter 
or  other  instrument  in  a  case  of  enlargement  of  the  prostate 
should  be  carried  out  with  the  greatest  care  in  regard  to  asepsis 
and  the  avoidance  of  injury  to  the  urethra.  The  examination 
should  be  made  with  the  patient  in  bed,  and,  if  possible,  he 
should  be  prepared  by  the  administration  of  urotropine  and  some 
diuretic  such  as  Contrexeville  water  or  tea. 


Lvi]    ENLARGED   PROSTATE:   EXAMINATION    699 

To  ascertain  if  there  is  residual  urine  the  patient  is  directed 
to  pass  water  standing  up  and  then  to  Ue  on  his  bed.  A  soft  rubber 
catheter  or  a  coude  catheter  is  gently  passed,  and  the  urine  which 
remains  in  the  bladder  is  drawn  off  and  measured. 

Sounding. — Information  may  be  obtained  by  the  passage  of 
a  metal  instrument  such  as  a  calculus  sound.  Obstruction  is  felt 
by  the  experienced  touch  in  the  prostatic  urethra.  The  instrument 
must  be  depressed  deeply  between  the  thighs  befort.  the  beak 
will  enter  the  bladder.  The  length  of  the  urethra  is  increased, 
and  the  instrument  may  sink  in  to  the  handle  before  the  beak 
rides  over  the  prostate  at  the  internal  meatus.  When  the  beak 
is  in  the  bladder  the  handle  can  be  freely  turned  from  side  to  side. 
On  turning  the  beak  downwards  and  withdrawing  the  instrument 
it  will  hitch  when  the  beak  comes  in  contact  with  the  bladder 
surface  of  the  prostate,  and  the  length  of  the  urethra  can  thus 
be  estimated. 

Cystoscopy. — The  cystoscope  shows  the  condition  of  the  upper 
or  bladder  surface.  The  outline  of  the  normal  margin  of  the 
urethral  orifice  as  seen  by  the  cystoscope  is  slightly  concave.  A 
convex  surface  surrounds  the  orifice  when  a  collar-like  intravesical 
enlargement  is  present.  One  lobe  may  be  seen  to  project  into  the 
bladder  as  a  round  swelling  like  the  end  of  an  egg,  or  there  may 
be  a  median  globular  swelling  when  a  median  lobe  is  present. 
When  both  lobes  project  into  the  bladder  the  opening  between 
them  into  the  bladder  is  V-shaped  when  viewed  with  the  cysto- 
scope partly  withdrawn  into  the  urethra.  The  size  of  the  projec- 
tion may  be  estimated  by  noting  whether  it  obscures  the  ureteric 
orifices.  On  the  surface  of  the  intravesical  portion  may  be  seen 
large  raised  veins  ;  occasionally  there  are  tags  of  mucous  mem- 
brane, each  containing  a  vessel,  or  there  may  be  sago-grain-like 
swellings  due  to  blocked  glands. 

Trabeculation  and  sacculation  of  the  bladder  are  noted. 

Cystitis,  dilatation  of  the  ureteric  orifices,  and  calculi  may  be 
observed. 

Examination  for  evidence  of  renal  failure  should  be  made 
{see  p.  10). 

Complications. — During  the  course  of  the  disease  certain 
complications  may  arise,  viz.  retention  of  urine,  septic  infection, 
haemorrhage,  renal  failure,  epididymitis,  stone,  stricture. 

Several  of  these  complications  have  already  been  described  in 
discussing  the  symptoms,  and  need  no  further  notice. 

Septic  infection. — The  obstructed  bladder  is  congested,  and 
its  powers  of  resistance  are  diminished.  It  therefore  forms  a  ready 
field  for  the  culture  of  bacteria  if  they  are  introduced.     Infection 


700 


THE  PROSTATE 


[chap. 


usually  follows  the  use  of  the  catheter.     The  onset  of  symptoms 
may  be  sudden  and  severe,  or  insidious. 

In  the  former  case,  a  few  hours  after  the  passage  of  a  catheter 
there  is  a  rigor,  and  the  temperature  rises  to  102°  F.  or  higher, 
and  continues  high.  The  urine  rapidly  becomes  cloudy  and  alka- 
line, and  may  be  ammoniacal.  There  is  increased  frequency  of 
micturition,  with  scalding  and  straining,  and  sometimes  retention 
of  urine  occurs,  with  great  pain.  There  is  renal  aching  or  actual 
renal  pain,  usually  confined  to  one  side.  Tenderness  is  present 
over  the  kidney  on  one  or  both  sides.      The  tongue  becomes  dry, 

the  mouth  parched,  and 
the  patient  complains 
of  burning  thirst.  There 
are  nausea  and  anorexia 
and  constipation,  and 
all  but  fluid  food  is 
refused.  The  patient  be- 
comes drowsy,  sometimes 
with  intervals  of  rest- 
less delirium ;  these  occur 
especially  at  night,  when 
he  shows  great  anxiety 
to  get  out  of  bed  and 
to  remove  dressings  or 
the  catheter  if  one  be 
tied  in  the  urethra.  The 
urine  becomes  scanty ; 
vomiting  and  hiccough 
supervene,  and  eventu- 
ally death,  with  partial  or  complete  suppression  of  urine. 

But  the  onset  may  be  insidious  and  the  course  less  rapid.  A 
slight  degree  of  pyelonephritis  is  present,  and  the  most  prominent 
feature  is  cystitis. 

Renal  failure  may  be  acute  or  chronic.  After  rapid  and 
complete  removal  of  the  urine  from  an  over-distended  bladder, 
whether  the  distension  is  acute  or  chronic,  suppression  not  infre- 
quently occurs.  The  urine  may  be  only  partly  or  completely 
suppressed,  the  patient  becomes  drowsy,  and  gradually  sinks  and 
dies  a  few  days  after  the  passage  of  the  catheter  {see  Anuria, 
p.  15).  Chronic  renal  failure  is  a  common  complication  of  un- 
treated enlarged  prostate.  There  are  thirst,  headache,  nausea, 
anorexia,  constipation,  loss  of  weight,  a  dry  tongue,  and  sallow 
complexion.  Renal  aching  is  often  observed,  and  polyuria  con- 
stantly present. 


Fig.  214. — Collection  of  round  uric-acid 
calculi  from  postprostatic  pouch. 


Lvi]       ENLARGED   PROSTATE:   PROGNOSIS        701 


Epididymitis  is  a  frequent  complication  when  sepsis  has  been 
introduced.  It  occurs  usually  in  cases  in  which  a  catheter  is  in 
constant  use. 

Calculi  are  present  in  the  bladder  in  7  per  cent,  of  cases. 
They  are  composed  of  oxalate  of  lime,  or  uric  acid,  or  phosphates. 
The  phosphatic  calculi  are  found  with  alkaline  or  decomposing 
urine.  There  may  be  one  or  many  calcuU  (thirty  or  forty). 
Uric-acid  and  oxalate  calculi  assume  their  characteristic  shapes 
(Fig.  214),  phosphatic  calculi  are  faceted  (Fig.  215).  The  stones 
usually  lie  in  the  postprostatic  pouch,  where  they  may  be  fixed 
and  give  rise  to  no  symptoms.  Larger  calculi  may,  however,  move 
freely  and  give  rise  to 
the  characteristic  symp- 
toms of  stone. 

Stricture  is  an  in- 
frequent complication  of 
enlarged  prostate. 

Course  and  prog- 
nosis.— Enlarged  pros- 
tate is  a  progressive 
condition  which,  if  un- 
treated, leads  to  a  fatal 
termination.  It  is  serious 
because  of  the  urinary 
obstruction  which  it  pro- 
duces, and  the  septic 
complications  which  are 
so  frequently  superadded. 
on  malignant  characters. 

The  earliest  stage  is  that  of  irritation,  and  this  is  followed 
by  increasing  obstruction,  against  which  the  bladder  conteiids 
forayariable  time,  lasting  usually  sonie  years.  Eventually  the 
Lladder  muscle  is  unable  to  overcome  the  obstruction,  and  com- 
plete retention  ensues.  During  the  period  of  increasing  obstruc- 
tion a  moderate  degree  omilatation  of  the  Iddneys,  and  withTlt 
interstitial  nephritis,  develops.  Sepsis  introduced  by  means  of 
the  catheter  causes  cystitis  and  ascending  pyelonephritis^;  which 
leacTs^immediately  "or  after  some  time  to  a  fatal  result.  Occasion- 
ally there  is  complete  retention  from  the  first  onset  of  symptoms. 

Diagnosis. — The  characteristic  features  of  enlarged  prostate 
are  that  the  symptoms  commence  at  or  after  the  age  of  50,  that 
the  first  symptoms  are  those  of  bladder  irritation,  that  there  is 
rarely  sudden  complete  retention,  that  the  frequent  micturition 
is  of  the  "  prostatic  "  type,  and  that  the  rectal  examination  shows 


Fig.  215. — Collection   of  faceted    phos- 
phatic calculi  from  postprostatic  pouch. 

Earely  the  simple  enlargement  takes 


702  THE   PROSTATE  [chaf. 

an  elastic  uniform  enlargement  of  the  organ,  wkile  cystoscopic 
examination  demonstrates  an  intravesical  projection. 

In  urethral  stricture  the  symptoms  commence  before  the  age 
of  50,  usually  before  the  age  of  30,  there  is  gradually  increasing 
difficulty  in  micturition  without  increased  frequency,  the  prostate 
is  not  enlarged  per  rectum,  and  there  is  obstruction  in  the  penile 
or  bulbous  urethra  to  the  passage  of  instruments. 

Malignant  disease  of  the  prostate  may  begin  at  an  earlier  age 
than  simple  enlargement,  but  the  average  age  is  the  same.  There 
is  gradually  increasing  obstruction,  usually  without  irritation  in 
the  early  stage  ;  when  frequent  micturition  appears  it  occurs  at 
regular  intervals  and  is  not  of  the  "  prostatic  "  type  ;  haemorrhage 
is  less  frequent  than  in  simple  enlargement ;  loss  of  weight  may 
be  present ;  the  lymphatic  glands  in  the  groins  are  frequently 
enlarged  ;  the  prostate  is  hard,  irregular,  fixed,  and  there  may 
be  enlarged  glands  on  each  side  of  it ;  no  intravesical  projection 
is  present,  or  there  is  irregular  elevation  of  the  urethral  margin. 

Chronic  prostatitis  usually  commences  before  the  age  of  50 ; 
there  are  bacteria  in  the  urine  ;  the  prostate  is  not  enlarged  per 
rectum,  but  is  tender,  firm,  and  sometimes  irregular  ;  there  is  no 
intravesical  projection  of  the  gland. 

When  the  diagnosis  of  enlarged  prostate  is  made  it  is  neces- 
sary to  ascertain — 

1.  Are  calculi  present  ? — In  a  movable  calculus  there  may 
be  the  typical  symptoms  of  stone  in  the  bladder,  but  in  calculi 
lying  in  a  postprostatic  pouch  there  are  no  symptoms  pointing  to 
their  presence.  The  previous  passage  of  calculi  may  raise  a  sus- 
picion ;  haemorrhage  is  usually  present ;  the  sound  will  ring  upon 
the  stone  if  the  prostate  is  not  very  large,  but  when  the  intravesical 
projection  is  considerable  and  the  postprostatic  pouch  deep  the 
sound  does  not  strike  the  calculi.  By  raising  the  pelvis  before 
sounding  in  such  a  case  the  stones  may  be  so  displaced  as  to  come 
within  the  range  of  the  beak  of  the  sound.  The  cystoscope  will 
detect  calculi  lying  deeply  behind  the  prostate,  but  occasionally 
they  are  not  found  until  prostatectomy  is  commenced. 

2.  Is  the  bladder  permanently  atonic  ? — The  view  of 
Guyon  that  the  bladder  is  permanently  disabled  by  sclerosis  is 
now  abandoned,  but  in  rare  cases  the  bladder  remains  atonic 
after  the  prostate  has  been  removed.  In  these  cases  there  is  an 
entire  absence  of  the  irritative  symptoms  of  enlarged  prostate, 
while  the  inability  to  pass  urine  is  early  manifested.  Diverticula 
of  the  bladder  wall  are  not  infrequently  found  in  such  cases. 
Usually  it  is  impossible  before  removing  the  prostate  to  diagnose 
this  condition. 


Lvi]      ENLARGED   PROSTATE:   TREATMENT      703 

3.  What  is  the  condition  of  the  kidneys? — The  symptoms  of 
renal  failure  should  be  searched  for,  the  specific  gravity  of  the 
urine  ascertained,  and  the  urea  estimated  quantitatively.  The 
tests  for  the  renal  function  should  be  employed  (p.  20).  It  may 
be  accepted  that  in  all  cases  of  chronic  retention  with  distensipii, 
the  kidneys  are  damaged. 

Treatment.  1.  Treatment  of  complications,  (a)  Retention 
of  urine. — I'liis  may  take  the  form  of  complete  retention  of  urine 
or  chronic  distension  of  the  bladder  with  power  to  pass  small  quan- 
tities of  urine  voluntarily.  It  is  a  serious  complication,  and  if 
treated  injudiciously  may  lead  to  a  fatal  result.  The  two  dangers 
to  be  avoided  are  rapid  emptying  of  the  bladder,  which  is  frequently 
followed  by  haemorrhage  and  suppression  of  urine,  and  the  intro- 
duction of  sepsis.  The  most  rigid  precautions  should  be  adopted 
in  order  to  prevent  infection,  and  in  chronic  distension  the  patient 
should  be  placed  upon  some  urinary  antiseptic  (urotropine,  10  gr. 
thrice  daily)  for  several  days  before  the  distension  is  relieved. 
He  should  be  in  bed  and  in  a  warm  atmosphere,  and  after  the 
catheter  has  been  passed  is  surrounded  with  hot  bottles  and  should 
drink  a  tumbler  of  hot  milk  or  tea.  The  catheters,  whether  gum- 
elastic  or  metal,  must  be  boiled,  the  hands  carefully  cleansed,  the 
penis  washed  with  antiseptic,  and  the  urethra  irrigated  with  anti- 
septic solution. 

The  most  useful  instruments  are  the  coude  and  bicoude  silk- 
wove  catheters  ;  the  latter  may  be  obtained  specially  long  (16  in.) 
for  use  in  very  large  prostates.  These  should  be  boiled  {see 
pp.  354,  562)  and  placed  in  cold  sterile  water.  A  "  prostatic  " 
metal  catheter  is  one  with  a  very  large  curve,  and  is  often  useful. 
A  gum-elastic  catheter  provided  with  a  stilet  may  be  used ;  it 
can  be  moulded  in  hot  water  into  a  suitable  shape,  and  fixed 
in  cold  water. 

The  lubricant  must,  of  course,  be  sterile.  A  good  lubricant 
is  boiled  olive  oil  {see  p.  356). 

The  coude  and  bicoude  instruments  should  be  tried  first,  and 
may  pass  easily.  When  a  difficulty  is  encountered  the  catheter 
should  be  pushed  on  with  the  utmost  gentleness,  the  beak  being 
inclined  to  one  or  other  side  if  necessary. 

In  passing  instruments  it  should  be  remembered  that  the 
anterior  wall  of  the  prostatic  urethra  remains  straight  and  almost 
vertical ;  that  the  urethra  is  pushed  to  one  side  when  one  lobe  is 
more  enlarged,  and  this  can  be  ascertained  by  rectal  examination ; 
that  the  verumontanum  sinks  backwards  so  that  the  posterior 
wall  forms  a  deep  pocket  or  angle  at  this  level ;  that  the  pos- 
terior lip  of  the  vesical  orifice  is  raised  and  projected  forwards, 


704  THE   PROSTATE  [chap. 

and  that  a  middle  lobe  forms  a  Y-shaped  vesical  opening  along 
one  limb  of  which  the  beak  of  the  instrument  travels. 

If  the  coude  and  bicoude  instruments  fail  a  metal  instrument 
may  be  tried,  or  an  English  gum-elastic  catheter,  softened  in  hot 
water,  so  bent  that  it  has  a  large,  sweeping,  very  full  curve,  and 
then  fixed  in  cold  water.  A  method  sometimes  recommended  is 
to  introduce  a  gum-elastic  instrument  with  the  stilet  in  place, 
and  when  the  beak  is  in  the  prostatic  urethra,  withdraw  the  stilet 
a  little,  thus  pulling  the  beak  forwards. 

It  is  important  not  to  empty  the  bladder  rapidly.  Only  10 
or  15  oz.  should  be  drawn  off ;  after  an  interval  of  half  an  hour 
a  similar  amount  is  withdrawn,  and  so  on  until  the  bladder  is 
empty,  the  catheter  being  retained  in  the  urethra  meanwhile  and 
plugged.  Another  method  is  to  tie-in  a  catheter  of  very  small 
calibre  (5  or  6  Fr.)  and  allow  the  urine  to  trickle  away  continuously, 
the  bladder  being  emptied  in  about  one  and  a  half  to  two  hours. 
When  the  bladder  is  empty  a  few  syringefuls  of  nitrate-of-silver 
solution,  1  in  15,000,  should  be  injected  and  allowed  to  flow  away. 
Stimulants  are  usually  necessary  in  these  cases.  The  catheter 
should  be  tied  in,  and  the  patient  kept  in  bed  for  several  days. 
At  the  end  of  that  time  a  decision  will  have  to  be  made  as  to 
whether  "  catheter  life "  is  to  be  commenced  or  an  operation 
performed. 

(b)  Hcemorrhage. — Haemorrhage  may  follow  the  passage  of 
a  catheter.  The  patient  should  be  confined  to  bed,  and  ergot  or 
calcium  lactate  (10  gr.  thrice  daily  for  two  days)  given,  and,  if  the 
renal  function  is  not  seriously  impaired,  a  little  morphia.  The 
bladder  should  be  washed  with  a  large  quantity  of  weak  silver 
nitrate  solution,  1  in  10,000.  If  the  haemorrhage  is  severe  and 
persistent,  suprapubic  cystotomy  and  prostatectomy  may  be 
necessary. 

(c)  Frequent  micturition. — This  symptom  is  frequently  due  to 
the  presence  of  residual  urine,  stone,  and  sepsis.  Residual  urine 
is  treated  by  catheterism  or  prostatectomy ;  stone  is  removed  at 
the  operation  of  prostatectomy ;    sepsis  is  referred  to  below. 

Belladonna  must  be  avoided,  as  its  use  will  be  followed  by 
an  increase  in  the  residual  urine,  and  sometimes  by  complete 
retention. 

(d)  Sepsis. — The  treatment  of  cystitis  is  usually  ineffectual 
unless  bladder  drainage  is  obtained.  Prostatectomy  is  the  best 
method  of  obtaining  this,  but  before  the  operation  the  cystitis 
should  be  reduced  as  far  as  possible  by  washing  the  bladder  or  by 
tying  a  catheter  in  the  urethra.  In  severe  cystitis  which  has 
resisted  these  measures  the  operation  of  prostatectomy  should  be 


Lvi]  CATHETER   LIFE  705 

performed  in  two  stages.  The  first  stage  consists  in  suprapubic 
cystotomy  and  drainage  by  a  large  rubber  tube.  This  is  followed 
by  daily  washing  of  the  bladder  or  continuous  irrigation.  The 
second  stage  consists  in  removal  of  the  prostate,  and  is  carried 
out  ten  or  fourteen  days  later.  Where  prostatectomy  is  contra- 
indicated  and  pyelonephritis  is  present,  the  bladder  should  be 
drained  by  catheter,  or,  better,  by  suprapubic  cystotomy.  Treat- 
ment for  cystitis  and  pyelonephritis  should  then  be  carried  out 
(pp.  134,  430). 

2.  Non-operative  treatment  :  catheter  life.— Catheter  life 
consists  in  the  regular  passage  of  a  catheter  to  withdraw  residual 
urine.  It  is,  of  course,  only  the  treatment  of  a  symptom,  and 
does  not  cause  diminution  of  the  size  of  the  prostate  or  cure  the 
disease.  The  catheterization  may  be  carried  out  by  the  patient 
or  by  a  trained  attendant. 

For  practising  catheterization  the  following  materials  are 
necessary : — 

1.  An  easily  prepared  antiseptic  solution.  Soloids  of  mercuric 
potassium  iodide,  each  1-75  gr.,  in  a  bottle  of  fifty,  is  a  convenient 
form.  One  soloid  is  added  to  1  pint  of  water  and  forms  a  solu- 
tion of  1  in  5,000. 

2.  Surgical  absorbent  wool,  or  prepared  surgical  swabs. 

3.  Two  or  more  rubber  catheters  (No.  7  or  No.  8  E.),  or  a  silk- 
wove  coude  or  bicoude  catheter. 

4.  A  steriHzer.  A  spirit-lamp  and  metal  pan  will  serve,  but  a 
more  convenient  form  is  Zuckerkandl's  catheter  sterihzer  (p.  355). 

5.  An  antiseptic  non-irritating  lubricant  (p.  356)  in  a  collapsible 
tube. 

6.  A  glass  syringe  of  2  oz.  capacity  for  washing  the  catheter. 

7.  Two  bowls  of  japanned  metal  or  of  ware,  which  are  steriUzed 
by  burning  in  them  two  teaspoonfuls  of  methylated  spirit. 

8.  A  glass  irrigator  with  a  capacity  of  2  pints  or  over,  rubber 
tubing,  an  easily  manipulated  chp,  and  a  glass  nozzle  which  will 
fit  the  end  of  the  catheter.  These  are  only  required  if  the  bladder 
is  to  be  irrigated. 

The  patient  is  taught  that  bacteria  are  his  chief  danger,  and 
that  they  exist  everywhere  and  on  everything  that  has  not  been 
boiled  or  washed  with  an  antiseptic. 

A  clean  towel  is  spread  over  a  small  table  and  all  the  materials 
are  placed  upon  it.  The  antiseptic  solution  is  prepared  in  one  bowl, 
the  second  being  used  as  a  receptacle  for  the  urine.  The  patient 
washes  his  hands  and  soaks  them  in  antiseptic.  The  catheter  is 
sterilized  and  placed  in  the  bowl  of  lotion.  The  screw  cap  of  the 
lubricant  tube  is  removed  and  the  top  plunged  in  boiling  water. 


706  THE   PROSTATE  [chap. 

The  hands  and  penis  are  washed  with  soap  and  water  and  then 
with  antiseptic,  and  the  patient  stands  over  the  second  bowl 
placed  on  the  table  or  on  a  chair.  A  little  lubricant  is  squeezed 
on  the  end  of  the  catheter,  which  is  held  in  the  right  hand 
2  or  3  in.  from  its  point.  The  penis  is  held  between  the  thumb 
and  forefinger  of  the  left  hand  and  the  catheter  slowly  passed. 
Resistance  is  felt  at  the  membranous  urethra  and  in  the  prostatic 
portion,  and  is  overcome  by  gentle  steady  pressure  or  by  a  spiral 
movement  by  twisting  the  outer  end.  When  the  urine  begins 
to  flow  the  end  is  turned  down  into  the  bowl,  and  when  it  has 
ceased  the  lumen  of  the  catheter  is  occluded  by  pressure  with 
the  finger  and  thumb  and  the  instrument  steadily  withdrawn. 

The  catheter  is  at  once  washed  in  soap  and  water  and  anti- 
septic fluid  and  syringed  through.  It  is  thoroughly  dried  and 
placed  in  a  japanned  catheter  box  or  a  glass  tube  closed  at  each 
end  with  a  rubber  plug,  or  it  may  be  kept  in  a  clean  handkerchief. 

The  patient  may  pass  his  catheter  lying  in  bed. 

If  cystitis  is  already  present  it  will  be  necessary  to  irrigate  the 
bladder  once  or  several  times  a  day.  This  is  done  when  the  urine 
has  been  withdrawn.  The  antiseptic  fluid  (boric  acid  solution,  1 
teaspoonful  of  the  crystals  to  a  pint  of  water  ;  potassium  per- 
manganate solution,  1  drachm  of  a  saturated  solution  to  2  pints  of 
water ;  oxycyanide  of  mercury,  1  in  5,000)  has  previously  been 
prepared,  and  the  irrigator  is  placed  on  the  mantelshelf  or  on  a 
hook  2  or  3  ft.  above  the  level  of  the  bladder.  The  nozzle  of  the 
irrigator  is  applied  to  the  catheter,  and  4  or  5  oz.  run  in  and  then 
discharged,  and  this  is  repeated  until  the  irrigator  is  empty. 

If  catheterization  is  performed  by  the  patient  away  from  home 
the  catheter  is  sterilized  before  leaving  home  and  placed  in  an 
aseptic  metal  box  (p.  356). 

If  the  residual  urine  does  not  exceed  3  or  4  oz.  the  catheter 
is  passed  once  or  twice  a  week  ;  if  it  is  in  greater  quantity  the 
catheter  is  passed  every  night,  or  night  and  morning.  When 
retention  is  complete,  or  there  is  distension  of  the  bladder  with 
voluntary  micturition,  the  catheter  should  be  passed  three  or 
five  times  in  the  twenty-four  hours.  The  patient  should  take 
urinary  antiseptics  regularly  (urotropine,  hetralin,    etc.). 

The  dangers  of  this  method  are  infection  and  haemorrhage.  In 
the  majority  of  cases  the  method  breaks  down  sooner  or  later  by 
the  introduction  of  sepsis,  or  from  the  difficulty  of  passing  the 
instrument,  or  from  haemorrhage.  The  mortality  of  catheter  life 
has  been  stated  to  be  7-7  per  cent,  in  the  hands  of  a  competent 
surgeon.  It  is  many  times  this  figure  when  the  patient  uses 
his  own  catheter  or  the  medical  attendant  is  unskilled  in  urethral 


Lvi]  PROSTATEGTOiMY  :  SELECTION  OF  GASES  707 

surp;ery.  It  is  certainly  very  high,  and  to  it  nnist  be  added 
tlie  cases  in  which  death  follows  on  operation  performed  in 
desperate  circumstances  when  catheter  life  has  failed. 

In  order  to  carry  out  catheter  life  with  comparative  safety  the 
patient  must  be  wealthy,  leisured,  methodical,  patient,  and  his 
health  nuist  be  sufficiently  good  to  allow  him  to  perform  the 
delicate  operation  with  constant  care  and  every  precaution.  And 
for  the  same  reason  his  hand  must  not  be  tremulous  nor  liis 
eyesight  failing  ;  nor  must  he  be  so  stout  that  his  penis  is  con- 
cealed from  his  view. 

As  the  age  of  the  patient  increases  he  becomes  less  able  to 
carry  out  the  necessary  routine,  while  the  increasing  size  of  the 
prostate  makes  the  operation  more  difficult. 

There  is  no  justification  for  recommending  catheter  life  with  a 
view  to  operation  later,  should  it  fail.  If  operation  is  to  be  per- 
formed, it  should  be  done  under  the  best  conditions  possible — 
that  is,  when  the  urinary  tract  is  aseptic  and  the  general  health 
of  the  patient  good.  Catheter  life  is,  in  fact,  only  indicated  when 
operative  treatment  cannot  be  carried  out. 

3.  Operative  treatment.  —  Only  one  method  of  treatment 
need  be  discussed,  namely,  ]jrostatectomy.  Prostatotomy,  Bottini's. 
galvano-caustic  incision,  castration,  vasectomy,  and  other  methods 
are  of  merely  historical  interest. 

Prostatectomy.  Selection  of  cases  for  operation. — The  majority 
of  the  patients  who  suffer  from  enlarged  prostate  are  old  men  ; 
the  average  in  112  of  my  cases  of  prostatectomy  Avas  66  years. 
They  are  frequently  in  broken  health  from  loss  of  sleep,  and  their 
strength  is  sapped  by  urinary  sepsis  and  deficient  elimination. 
If  an  optional  major  operation  for  some  extra -urinary  condition 
were  discussed  it  is  certain  that  it  would  be  refused  on  account 
of  the  general  condition  of  the  patient  in  a  very  large  number 
of  these  patients.  Prostatectomy  ranks  as  a  serious  major  opera- 
tion with  three  immediate  dangers  —  shock,  haemorrhage,  and 
uraemia.  It  is,  however,  an  operation  of  necessity  in  most  cases, 
and  the  results  of  skilfully  conducted  prostatectomy  are  little 
short  of  miraculous  in  even  the  most  unpromising  cases. 

Old  age  does  not  of  itself  contra-indicate  prostatectomy.  The 
mortality  does  not  increase  pari  passu  with  the  age.  In  83 
cases  the  death-rate  was  greater  between  the  ages  of  55  and 
60  than  between  66  and  70  or  over  75.  Many  patients  over  80 
have  now  been  operated  upon  successfully.  My  oldest  patient 
was  86  years,  and  had  suffered  from  severe  haemorrhage  for  six 
weeks  before  the  operation.  Freyer  records  19  cases  of  80  or 
over  with  2  deaths.     Elsewhere   he  states  that  he  has  operated 


708  THE   PROSTATE  [chap. 

upon  47  octogenarians  between  80  and  89  years  and  upon  9 
aged  79. 

The  feeble  resistance  of  these  aged  patients  must,  however, 
be  borne  in  mind.  The  operative  measures  should  be  carried  out 
with  the  utmost  dispatch,  and  every  care  taken  to  maintain  the 
circulation  and  prevent  bronchitis.  Skilled  nursing  after  the 
operation  contributes  largely  to  success  in  these  old  patients. 

The  condition  of  the  lungs  is  an  important  factor.  Chronic 
bronchitis  is  a  grave  complication,  and  may  contra  -  indicate 
prostatectomy.  When  bronchitis  is  present  spinal  anaesthesia 
should  be  employed,  and  the  patient  placed  in  the  sitting  posture 
and  in  a  warm  atmosphere  after  the  operation. 

Valvular  cardiac  disease  is  not  a  contra-indication  if  com- 
pensation is  perfect.  I  have  operated  in  cases  both  of  mitral 
and  of  aortic  disease.  Disease  of  the  cardiac  muscle  is,  however, 
a  grave  complication,  and  may  lead  to  cardiac  failure  some  hours 
or  even  days  after  the  operation. 

Disease  of  the  kidneys  is,  equally  with  bronchitis,  the  greatest 
danger.  Many  patients  who  have  been  on  catheter  life  sufier 
from  "  urinary  septicaemia,"  a  combination  of  septic  absorption 
and  uraemia  due  to  urinary  obstruction  and  renal  infection.  In 
other  cases  there  is  an  inefficient  renal  function  from  urinary 
obstruction  without  infection.  In  all  these  cases  the  operation 
should  be  performed  in  two  stages,  a  preliminary  suprapubic 
cystotomy  being  first  performed,  and  the  prostate  removed  two 
or  three  weeks  later.  By  this  method  patients  suffering  from 
advanced  uraemia  and  profoimd  sepsis  have  successfully  under- 
gone prostatectomy.  ^ 

Disease  of  the  nervous  system  does  not  necessarily  contra- 
indicate  prostatectomy.  I  have  operated  successfully  in  a  case  of 
multiple  sclerosis,  and  operations  have  been  performed  on  patients 
suffering  from  old-standing  hemiplegia. 

Cystitis,  if  severe  and  chronic,  should  be  treated  by  bladder 
washing,  and  occasionally  preliminary  cystotomy  and  drainage 
for  ten  or  fourteen  days  are  necessary.  Vesical  calculus  does 
not  increase  the  danger  of  the  operation.  Large  diverticula  are 
occasionally  present.  The  presence  of  a  diverticulum  does  not 
contra-indicate  prostatectomy,  but  in  these  cases  there  is  usually 
residual  urine  after  the  prostate  has  been  removed. 

Prostatectomy  should  be  performed  whenever  the  prostate  is 
recognized  as  enlarged,  while  the  urine  is  still  aseptic,  and  before 
the  kidneys  are  damaged  by  back  pressure.  It  is  unnecessary  to 
wait  until  residual  urine  appears,  or  until  the  patient  is  becoming 
worn  out  by  loss  of  sleep. 


Lvi]  SUPRAPUBIC   PROSTATECTOMY  709 

Preparations  for  the  oferation. — It  is  necessary  to  treat  bron- 
chitis, constipation,  and  other  concurrent  conditions  before  the 
operation. 

Urinary  antiseptics  and  diuretics  should  be  freely  given  when 
sepsis  and  renal  complications  are  present. 

In  cases  of  chronic  cystitis  some  days  or  even  weeks  may  be 
usefully  employed  in  washing  the  bladder  with  antiseptic  solution. 

Preliminary  suprapubic  cystotomy  with  drainage  should  be 
performed  in  cases  of  chronic  distension  of  the  bladder  after  first 
very  slowly  emptying  the  bladder  {see  p.  703),  in  cases  of  in- 
tractable chronic  cystitis,  and  in  cases  of  uraemia  or  of  urinary 
septicaemia. 

There  are  two  routes  by  which  prostatectomy  is  performed, 
the  suprapubic  and  the  perineal. 

Suprapubic  prostatectomy. — The  operation  of  complete  supra- 
pubic prostatectomy  here  described  was  introduced  by  Freyer  in 
1901,  and  is  now  universally  accepted  in  Europe  as  the  best  and 
most  successful  method  of  operating.  In  America  a  constantly 
increasing  number  of  surgeons,  as  shown  by  the  literature,  are 
adopting  the  method,  although  there  still  remain  a  few  strong 
advocates  of  the  perineal  route. 

A  catheter  is  passed  and  the  bladder  emptied  and  washed 
with  boric  solution.  From  10  to  12  oz.  of  fluid  are  introduced 
and  the  catheter  left  in  the  urethra  and  plugged.  The  surgeon 
stands  on  the  left  of  the  patient,  and  the  bladder  is  exposed  by  a 
vertical  medium  suprapubic  incision  3  in.  in  length  and  opened. 
A  narrow  retractor  or  hook  is  placed  in  the  upper  angle  of  the 
bladder  wound.  If  calculi  are  present  they  are  removed  by 
lithotomy  forceps  or  scoop.  The  left  hand  is  covered  with  a  rubber 
glove  and  the  forefinger  introduced  into  the  rectum.  Freyer  stands 
on  the  right  of  the  patient  and  introduces  the  right  forefinger  into 
the  rectum. 

The  forefinger  in  the  bladder  feels  for  the  most  prominent 
part  of  the  intravesical  projection  and  commences  the  enucleation 
by  stripping  the  mucous  membrane  from  the  back  or  vesical  sur- 
face of  this.  This  readily  peels  off  without  the  use  of  any  cutting 
instrument  and  without  using  a  sharpened  nail.  When  there  is 
no  prominent  intravesical  portion  the  forefinger  is  pushed  into 
the  prostatic  urethra  and  ruptures  the  posterior  wall  of  the  urethra 
and  commences  the  enucleation  in  this  way. 

At  the  base  of  the  intravesical  portion  the  finger,  guided  by  the 
prostate,  passes  within  the  circle  of  the  vesical  sphincter  between 
the  enlarged  prostate  and  its  sheath.  (Fig.  216.)  The  prostate  will 
be  found  to  enucleate  rapidly  and  without  difficulty.    First  one  lobe 


710 


THE   PROSTATE 


[chap. 


is  freed  by  sweeping  the  forefinger  around  it,  and  the  finger  passes 
across  the  middle  line  behind  the  prostate,  and  the  second  lobe 
is  treated  in  the  same  way.  There  may  be  difficulty  in  reaching 
the  lower  ends  of  each  lobe,  and  the  prostate  should  be  pushed 
up  with  the  rectal  finger.  The  second  finger  of  the  right  hand 
may  be  used  to  assist  in  enucleating  if  the  prostate  is  large  and 
difficult  to  reach.  The  finger  sweeps  across  the  middle  line  ante- 
riorly,  and    then    the  urethra  is   torn  across  upon  the  catheter 


Fig.  216. — Suprapubic  prostatectomy. 

Left  hand,  gloved,  with  forefinger  in  rectum  pressing  up  prostate.  Right  hand,  ungloved,  with 
forefinger  in  bladder.  The  tip  of  the  forefinger  has  stripped  the  bladder  mucous  membrane  of 
the  intravesical  portion   of  prostate,  and   is   being   insinuated   between   the   prostate  and   the 

vesical  sphincter. 

which  still  lies  in  it.  (Fig.  217.)  The  prostate  is  now  projected 
upwards  into  the  bladder.  The  left  forefinger  is  removed  from  the 
rectum,  the  glove  stripped  from  the  hand  by  an  assistant,  and  a 
pair  of  ovum  forceps  or  lithotrity  forceps  seized  and  introduced 
into  the  bladder,  guided  by  the  right  forefinger.  The  prostate  is 
grasped  and  removed.  A  copious  stream  of  hot  boric  lotion 
(120°  F.)  is  turned  on  through  the  catheter  from  a  reservoir.  A 
large  rubber  tube,  1  in.  in  diameter,  with  one  lateral  eye,  is  intro- 
duced into  the  bladder,   and  the  wound  in  the  bladder  wall  is 


LVl] 


SUPRAPUBIC  PROSTATECTOMY 


11 


closed  firmly  around  this  by  one  or  two  catgut  sutures.  A  small 
rubber  drain  is  placed  in  the  prevesical  space  (Freyer  uses  a  gauze 
wick),  and  the  abdominal  wound  is  closed  around  these  tubes, 
especial  care  being  taken  to  bring  the  edges  of  the  rectus  sheath 
together,  either  with  interrupted  catgut  sutures  or  with  a  con- 
tinuous catgut  thread.  The  catheter  is  removed.  The  lower  end 
of  the  bed  is  raised  on  blocks. 

On  the  following  day,  and  each  day  until  the  wound  is  closed, 
the  bladder  is  irrigated  through  the  suprapubic  wound  with  boric 


Fig.  217. — Suprapubic  prostatectomy. 

The  prostate  has  been  freed  behind,  laterally,  and  in  front  of  the  urethra,  and  the  point  of  the 
forefinger  is  in  the  act  of  tearing  the  prostatic  urethra  on  the  catheter  before  dislocating  the 

prostate  into  the  bladder. 

solution,  or  weak  biniodide  of  mercury  solution  (1  in  8,000),  or 
oxycyanide  of  mercury  solution  (1  in  5,000).  The  tubes  are  re- 
moved on  the  fourth  day.  A  purge  is  given  after  their  removal, 
but  care  should  be  taken  to  prevent  the  patient  from  straining. 
After  the  operation  the  urine  may  be  allowed  to  soak  into  the 
dressings,  which  are  changed  every  four  hours.  A  voluminous 
dressing,  consisting  of  a  few  lavers  of  gauze  next  the  wound  and 
much  cellulose  tissue  or  large  fiat  pads  of  wood-wool,  is  applied,  and 
retained  by  means  of  a  broad  binder  or  many-tailed  bandage 
extending  from  the  level  of  the  great  trochanters  to  above  the 


712 


THE  PROSTATE 


[chap. 


umbilicus.  THe  skin  is  protected  by  a  thick  covering  of  ointment 
containing  boric  acid,  zinc  oxide,  lanoline,  and  castor  oil.  As  an 
alternative,  a  Hamilton  Irving  apparatus  (p.  548)  may  be  applied 
at  the  end  of  the  operation.  It  is  changed  daily  and  thoroughly 
cleaned.  There  is  a  tendency  to  eversion  of  the  lips  and  conges- 
tion of  the  skin  with  this  apparatus,  and  the  wound  heals  more 
quickly  without  it.  It  is,  however,  much  more  economical,  and 
saves  the  constant  soaking  and  discomfort  and  frequent  dressing. 
The  wound  closes  in  from  three  to  four  weeks.  When  it  is 
almost  closed,   healing   will   be   expedited   by   tying   a   catheter 


Fig.  218. — Suprapubic  prostatectomy. 

Condition   of  parts  immediately  after  removal   of  the   prostate.      The   cavity  from  which   the 

prostate  has  been    removed  is  seen  with  the  catheter  passing  across  it  from  the  membranous 

urethra  to  the  bladder.     The  ledge  formed  by  the  bladder  base,  and  the  portion  of  the  posterior 

wall  of  the  prostatic  urethra  left  adherent  to  the  wall  of  the  prostatic  cavity,  are  represented. 

in  the  urethra.  In  one  of  my  cases  the  patient  left  the  nursing- 
home,  healed,  nineteen  days  after  the  operation  ;  this  is,  however, 
exceptional.  Occasionally  there  is  a  rise  of  temperature  (100°-101° 
F.)  when  the  patient  first  passes  urine  through  the  urethra,  but 
this  subsides  on  the  following  day. 

Surgical  anatomy  of  suprapubic  prostatectomy. — In  1904  I  in- 
vestigated the  surgical  anatomy  of  Freyer's  operation,  and  subse- 
quently (1905)  described  the  anatomical  and  clinical  conditions 
found  after  the  operation.  (Fig.  218.)  The  structures  removed 
consist  of  the  prostate  and  prostatic  urethra.    (Figs.  219-2.3.)    There 


Lvi]  PROSTATECTOMY :  SURGICAL  ANATOMY  713 

are  two  varieties.  In  one  there  is  an  intravesical  projection;  in 
the  other  the  prostate  is  wholly  extravesical.  The  specimen  (Figs. 
219-21)  consists  of  two  lobes  enclosed  in  an  envelope  of  circular 
fibres,  the  surface  of  which  is  usually  smooth.  The  intravesical 
portion,  when  one  is  present,  is  marked  off  from  the  extravesical 
portion  by  a  deep  groove  caused  by  the  sphincter  of  the  bladder. 
(Figs.  211,  219.)  There  is  a  single  median  lobe  behind  the  opening 
of  the  urethra,  or  two  lobes  at  the  sides.  When  a  single  median 
lobe  is  present  a  thick  band  of  muscular  fibres  is  seen  torn  across 
on  each  side  of  it.     This  is  the  remains  of  the  longitudinal  bands 


Fig.  219.  Fig.  220.  Fig.  221. 

Fig.  219. — Operation  specimen  of  enlarged  prostate,  anterior  view. 

Catheter  in  prostatic  urethra.      Bilobed  intravesical    projection  covered  by  mucous  membrane 
(upper  half),  and  extravesical  portion  covered  by  capsule  (lower  half). 

Fig.  220.^ — Posterior  view  of  same  specimen. 

Note  groove  between  intra-  and  extravesical  portions,  caused  by  pressure  of  sphincter.  Edge  of 
vesical  mucous  membrane  is  seen  at  upper  margin.  Posterior  wall  of  prostatic  urethra  from  the 
verumontanum  downwards  is  wanting,  having  been  left  adherent  to. the  wall  of  prostatic  cavity. 

Fig.  221. — Lateral  view  of  same  specimen. 

Note  bilobed  intravesical  portion  covered  with  mucous  membrane,  of  wnich  the  edge  is  seen. 

of  trigone  muscle,  which  pass  down  from  the  ureters  and  enter 
the  longitudinal  muscle  of  the  urethra. 

The  mucous  membrane  of  the  bladder  is  torn  across  on  the 
vesical  surface  of  the  intravesical  projection.  The  anterior  com- 
missure between  the  two  prostatic  lobes  is  complete  from  the 
vesical  orifice  of  the  urethra  to  the  lower  end  of  the  specimen, 
and  on  the  anterior  aspect  of  this  may  be  seen  portions  of  striped 


•14 


THE   PROSTATE 


[chap. 


muscle  fibre,  the  remains  of  tlie  vertical  portion  of  the  muscle  of 
Henle  (Fi»s.  224,  225),  and  sometimes  portions  of  the  veins  of  the 
vertical  limb  of  the  prostatic  venous  plexus.  The  posterior  com- 
missure is  complete  down  to  the  level  of  the  verumontanum,  and 
from  this  point  downwards  the  lobes  are  separate,  the  posterior 
wall  of  the  urethra  being  wanting.  The  verumontanum  can  some- 
times be  seen  at  the  lowest  part  of  the  portion  of  posterior  wall 
removed  with  the  prostate.    The  anterior  commissure  may  be  split 

during  the  enucleation,  and 
the  lobes  part  as  if  hinged 
posteriorly  and  display  the 
prostatic  urethra  (Fig.  223). 
The  prostatic  urethra  is  re- 
moved with  the  prostate, 
but  the  portion  of  the  pos- 
i;  terior  wall  extending  from 
'  the  verumontanum  down- 
wards is  usually  left  behind. 
Sometimes  a  strip  of  urethral 
wall  measuring  1 J  in.  is  torn 
out  with  the  prostate  and 
remains  attached  to  the  an- 
terior wall  of  the  prostatic 
urethra. 

After    removal    of     the 
prostate  there  remains  a  cav- 
ity between  the  bladder  and 
Fig.    222.— Specimen    of    enlarged    the-   membranous     urethra, 
prostate  after  prostatectomy.  ^p-gg  2I8,  226,  227.)  This  is 

Catheter    in    prostatic   urethra.     Groove    between  „„„ii  ,    „ f„j      ^^^ .     i^,,     +1,^ 

intra-    and    extravesical     portions.     Torn    edge    of  partly    rOOted     OVCr      by     the 

mucous    membrane    seen     on    intravesical     portion,  -t-mrrr^-rta   onrl     cm-no+ii-noa     -rxor-f 

circular  fibres  of  capsule  on  extravesical  portion.  WlgOnC  aUtt    SOmetimeS    part 

of  the  base  of  the  bladder, 
the  opening  into  the  bladder  being  at  the  anterior  part  of  the 
roof.  The  walls  are  formed  by  the  fascial  sheath  of  the  prostate, 
on  which  may  be  found  shreds  of  the  capsule  of  the  prostate,  and 
occasionally  a  small  adenomatous  nodule  is  left  adherent.  (Fig.  227.) 
A  strip  of  mucous  membrane  from  the  posterior  wall  of  the  pros- 
tatic urethra  from  the  verumontanum  downwards  is  often  adherent 
to  the  posterior  wall  of  the  cavity,  and  at  the  upper  end  of  this 
the  verumontanum  may  be  found. 

This  cavity  contracts  gradually  to  a  small  size,  but  even  after 
some  years  it  has  not  disappeared.    (Fig.  228.) 

I  have  sho\^^l  that  after  suprapubic  prostatectomy  the  sphincter 
at  the  orifice  of  the  bladder  becomes  active  and  competent  in  less 


Lvi]  PROSTATECTOMY:  SURGICAL  ANATOMY  715 


Fig.  223. — Specimen  of  enucleated  enlarged  prostate,  extravesical 
variety,  open  along  anterior  commissure. 

A.  B.    Mucous   membrane   of   prostatic   urethra.      C,   F,   Torn   mucous    membrane   at   internal 
meatus.     D.  Verumontanum.     E    Portion  of  posterior  wall  of  prostatic  urethra  wanting. 


Fig.  224. — Striped  muscle  in  capsule  of  enucleated  prostate. 

«.  Striped  muscle.     i\  Perivascular  infiltration. 


716 


THE  PROSTATE 


[chap. 


than  50  per  cent,  of  cases,  and  that  in  the  majority  of  cases  the 
urine  is  retained  by  the  contraction  of  the  striped  compressor 
urethrse  muscle  which  surrounds  the  membranous  urethra.  Fur- 
ther observations  tend  to  show  that  the  number  of  cases  in  which 
the  vesical  sphincter  resumes  control  is  smaller  than  I  had  sup- 
posed. 


'/>?*.;». 


Fig.  225. — Striped  muscle  lying  on  anterior  surface  of 
enucleated  prostate. 

a,  Striped  muscle  and  areolar  tissue.     ■'',  Capsule  of  prostate. 

Regeneration  of  the  prostate  does  not  occur  after  Freyer's 
operation. 

Partial  prostatectomy,  which  consists  of  shelling  adenoma 
from  within  the  prostate,  may  be  followed  by  recurrence  of  the 
growth  and  the  obstruction. 

Dangers   and   complications   oj    suprapubic   prostatectomy. — The 
chief  dangers  of  the  operation  are  : 
Shock. 
Haemorrhage. 


Lvi]  DANGERS  OF  PROSTATECTOMY  T17 

Urseinia. 
Septicsemia. 
Bronchitis,  pneumonia. 
Cerebral  haemorrhage  or  thrombosis. 
Pulmonary  embolism. 
Prostatectomy  ranks  high  in  the  list  of  operations  in  regard 
to  the  production  of  shock,  but  the  mortality  from  this  cause  is 


Fig.  226. — Bladder  and  prostatic  cavity  after  suprapubic 
prostatectomy. 

At  upper  part  is  bladder,  and  on  each  side  the  thickened  sphincter.     Below  this  is  the  cavity 

from   which  the  prostate  was  removed,  roofed    over   by  the   bladder  base.      On   the  posterior 

wall   of  this   are  a  portion  of  the   prostatic  urethra  and  the  ejaculatory  ducts.     In  its.walLare 

the  prostatic  veins,  and  at  the  lower  part  the  compressor  urethree  and  the  levator  ani. 

very  small.  It  is  avoided  by  careful  preparation  before  the  opera- 
tion and  by  rapid  operation,  and  is  treated  by  saline  infusion  and 
strychnine,  if  necessary,  after  the  operation. 

Hcemorrhage  is  sometimes  severe,  and  may  be  serious.  Flush- 
ing with  large  quantities  of  very  hot  water  (120°  P.)  immediately 
on  removal  of  the  prostate  is  a  routine  method  of  treatment.  On 
return  to  bed  the  lower  end  of  the  bed  is  raised  high  on  blocks 
and  a  hypodermic  injection  of  morphia  may  be  given. 

Should  severe  heemorrhage  continue  immediately  after  remova 


718 


THE   PROSTATE 


[chap. 

of  the  prostate,  or  should  it  occur  after  the  operation,  it  will  be 
necessary  to  pack  the  prostatic  cavity  with  strips  of  gauze  and 
then  introduce  the  large  drainage  tube  down  to  the  trigone.  The 
packing  is  removed  on  the  second  or  third  day,  a  short  anaesthesia 
being  sometimes  advisable.  I  do  not  hesitate  to  pack  the  pros- 
tatic cavity  when  there  is  the  slightest  anxiety  in  regard  to  haemor- 
rhage.    Secondary  hsemorrhage  may  very  rarely  occur  a  week  or 


Fig.  227. — Vertical  section  of  bladder  wall  and  wall  oi  cavity 
remaining  after  prostatectomy. 

A,  Bladder  muscle.     B,  Bladder  mucous  membrane.     C.  Prostatic  cavity.     D,  H,   Membranous 

urethra.     E,  Fibrous  wall   of  cavity  containing  veins  (F)  of  prostatic  plexus.     G,    Compressor 

urethrae   muscle.     I,   Striped  muscle  in   wall   of  cavity.     K,    Bladder  muscle   in    wall   of  cavity. 

L,  Small  portion  of  prostate  adherent  to  sheath. 

ten  days  after  the  operation,  and  is  due  to  sepsis,  or  to  allowing 
the  patient  too  much  liberty  in  sitting  up,  raising  himself,  and 
moving  about.  If  the  urine  remains  blood-stained  after  the  third 
day,  or  if  it  becomes  blood-stained  after  being  clear,  the  patient 
should  be  kept  flat,  with  the  lower  end  of  the  bed  raised,  and 
morphia  administered  hypodermically. 

Severe  secondary  hsemorrhage  is  treated  by  packing  the  pros- 
tatic cavity  and  reintroducing  the  bladder  drainage  tube. 


ivi]  DANGERS  OF  PROSTATECTOMY  719 

Urcemia  results  from  preoperative  disease  of  the  kidneys. 
When  there  is  evidence  of  renal  disease  the  operation  should  be 
performed  in  two  stages,  the  preliminary  cystotomy  preceding 
the  prostatectomy  by  a  week  or  longer. 

Energetic  diuretic  treatment  should  be  adopted  when  urajmia 
is  threatened  or  is  present.  Large  quantities  of  fluid  are  adminis- 
tered bv  the  mouth  and  diuretics  given  (theocin  sodium  acetate, 


Fig.  228.^ — Bladder  and  urethra  two  years  after  suprapubic 
prostatectomy. 

A,  Cavity  from  which  prostate  was  removed.  B,  Portion  of  posterior  wall  of  prostatic  urethra. 
C,  C,  Junction  of  prostatic  cavity  and  membranous  urethra.  D,  Junction  of  prostatic  cavity  and 
bladder.      E,    E,  .Fibrous   and   muscular  tissue   surrounding   cavity.     F,  F,    Malignant  growth 

in  bladder. 

10  gr.,  every  four  hours).  Rectal  and  hypodermic  infusion  of 
glucose  solution  (2  per  cent.)  and  intravenous  infusion  of  the 
same  solution  should  be  used.  Dry  cupping  and  hot  fomentations 
aje  applied  over  the  kidneys,  and  a  hot  pack  is  given  to  promote 
perspiration. 

Septic  infection  usually  results  from  an   exacerbation   of   pre- 


720  THE   PROSTATE  [chap. 

operative  cystitis,  and  takes  the  form  of  ascending  pyelonephritis ; 
it  is  frequently  complicated  by  suppression  of  urine.  Preventive 
treatment  should  be  carried  out  before  prostatectomy  is  per- 
formed. This  consists  in  the  administration  of  urinary  anti- 
septics and  in  bladder-washing,  continuous  drainage  by  catheter, 
or  suprapubic  cystotomy  and  free  daily  irrigation  of  the  bladder. 
When  ascending  infection  has  occurred  urinary  antiseptics  should 
be  administered  and  the  measures  detailed  under  Uraemia  adopted. 

Bronchitis  and  pneumonia. — The  treatment  consists  in  the  use 
of  spinal  anaesthesia  when  bronchitis  is  present  before  the  opera- 
tion, in  the  use  of  chloroform  and  not  ether  where  a  general 
ansesthetic  is  necessary,  in  rapid  operation,  and  in  free  administra- 
tion of  stimulants  and  cardiac  tonics  such  as  ergot  and  strophanthus. 

Epididymitis  may  appear  at  the  end  of  the  second  or  third 
week,  and  last  for  seven  to  ten  days. 

Results  of  suprapuhic  prostatectomy. — The  operative  mortality 
of  112  consecutive  cases  in  which  I  performed  complete  supra- 
pubic prostatectomy  was  5  per  cent.  (1910).  This  included  all  my 
earliest  cases,  performed  soon  after  the  introduction  of  the  opera- 
tion. In  1,000  cases  recorded  by  Freyer  the  operative  mortality 
was  5-5  per  cent.  This  observer  found  that  the  mortality  gradually 
decreased  from  10  per  cent,  in  the  first  100  cases  to  3  per  cent, 
in  the  last. 

Death  is  due  to  shock,  haemorrhage,  cardiac  failure,  uraemia, 
septicaemia,  bronchitis,  pneumonia,  pulmonary  embolism,  cerebral 
haemorrhage,  cerebral  thrombosis.  In  a  large  proportion  of  these 
cases  the  fatal  result  is  only  indirectly  connected  with  the  opera- 
tion, such  as  those  from  cerebral  haemorrhage  and  syncope  during 
convalescence  ;  in  others  it  is  due  to  an  exacerbation  of  pre- 
vious disease  of  the  kidneys  or  other  organs  which  would  have 
proved  fatal  within  a  short  time  had  the  operation  not  been 
performed. 

In  many  of  the  successful  cases  the  operation  was  performed 
when  the  patient  was  desperately  ill,  and  in  some  even  supposed 
to  be  moribund. 

The  late  results  are  very  satisfactory.  The  patient  is  able  to 
pass  urine  naturally,  and  wholly  empties  his  bladder,  even  in 
cases  where  there  has  been  complete  catheter  life  for  many  years 
(six  to  ten).  In  a  rare  class  of  cases  removal  of  the  prostate  by 
the  suprapubic  or  perineal  routes  is  not  followed  by  restoration 
of  the  bladder  function ;  these  belong  to  a  group  which  I  have 
described  elsewhere  {see  p.  537).  The  patient  has  complete  con- 
trol over  the  retention  of  urine  after  suprapubic  prostatectomy  ; 
I   have  not  seen  any  case   in   which  incontinence  was  present. 


Lvi]  SUPRAPUBIC   PROSTATECTOMY  721 

Cystitis  present  before  the  operation  is  usually  cured,  unless  due 
to  septic  pyelonephritis,  or  in  sacculated  bladders  or  those  in 
which  one  or  several  diverticula  are  present,  when  it  tends  to  per- 
sist. When  stone  is  present  before  the  operation  and  the  urine 
is  not  decomposing,  there  is  no  recurrence  after  the  operation.  If, 
however,  the  urine  is  decomposing  and  does  not  improve  after  the 
operation,  there  may  b )  a  recurrence  of  stone  formation.  Calculi 
of  the  former  type  are  usually  composed  of  uric  acid  or  oxalate  of 
lime  ;  those  which  recur  are  phosphatic.  Suprapubic  fistula  is 
rare  after  prostatectomy.  When  it  persists  it  can  be  cured  by 
operation  (p.  522).  In  112  consecutive  cases  there  were  2  in  which 
a  fistula  persisted;  both  were  cured  by  excision  of  the  fistula 
and  repair  of  the  bladder  wall.  Hernia  of  the  suprapubic  scar 
develops  in  rare  cases,  and  is  due  to  too  prolonged  drainage,  to 
neglect  to  repair  the  abdominal  wall  after  removing  the  prostate, 
or  to  allowing  a  heavy  patient  to  get  about  too  soon. 

The  sexual  function  was  unimpaired  in  47*5  per  cent,  of  cases ; 
in  32-5  per  cent,  desire  and  erection  were  normal,  but  there  was  no 
discharge  of  semen  ;  in  7' 5  per  cent,  a  failing  function  before  opera- 
tion showed  diminished  desire  after  operation  ;  and  in  12-5  per 
cent,  the  sexual  function,  which  was  very  feeble  or  abolished  before, 
showed  no  improvement  after  the  operation.  Where  the  function 
is  normal  except  for  the  emission,  the  semen  remains  in  the  pros- 
tatic cavity,  or  finds  its  way  into  the  bladder  and  is  discharged 
with  the  urine  at  the  next  micturition. 

Stricture  has  been  said  to  develop  after  operation  at  the  vesical 
outlet,  but  it  must  be  very  rare.  I  have  seen  one  case  in  which 
it  might  have  formed  but  was  prevented  by  tying-in  a  catheter 
for  a  week. 

Perineal  prostatectomy.— The  transverse  prerectal  incision 
of  Zuckerkandl  is  that  used  for  perineal  prostatectomy.  Proust 
has  elaborated  the  details  of  this  operation,  and  his  technique  is 
widely  followed. 

The  patient  is  placed  in  the  lithotomy  position,  the  pelvis 
being  raised  by  putting  a  hard  cushion  under  the  sacrum.  Proust 
described  a  position  {perineale  inverse)  in  which  the  dorsal  and 
lumbar  regions  are  supported  on  an  inclined  plane,  the  thighs 
flexed,  and  the  legs  held  vertically  by  a  framework.  In  this  posi- 
tion the  perineum  is  horizontal.  This  is  not  usually  considered 
necessary  for  the  operation.  A  stai¥  is  placed  in  the  urethra  and 
a  transverse  prerectal  or  curved  incision  with  the  convexity 
forwards  is  made  from  one  ischial  tuberosity  to  the  other, 
Ih  in.  in  front  of  the  anus.  The  posterior  end  of  the  bulb  is 
exposed,  the  ano-bulbar  raphe  seized  and  cut  across,  and  the 
2u 


722 


THE  PROSTATE 


[chap. 


two  forefingers  are  introduced  into  the  wound,  separating  the 
levatores  ani  muscles  and  pushing  back  the  rectum.  A  large 
retractor  is  now  placed  in  the  lower  part  of  the  wound  and  pulled 
backwards  to  the  coccyx  (Fig.  229),  displacing  the  rectum  back- 


Fig.  229. — Perineal  prostatectomy. 

The  bulb  has  been  exposed  and  pulled  forwards,  and  the  membranous  urethra  incised,  pre- 
paratory  to   introducing   the  prostatic  retractor.      The   levatores   ani   muscles  and   part  of  the 

prostate  are  seen. 

wards  and  exposing  the  posterior  surface  of  the  sheath  of  the 
prostate.  The  urethra  is  opened  at  the  apex  of  the  prostate, 
and  the  walls  are  picked  up  in  forceps.  The  staff  is  withdrawn 
and  a  depressor  is  introduced  through  the  prostatic  urethra  into 


LVl] 


PERINEAL    PROSTATECTOMY 


723 


the  bladder.  The  blades  are  separated  and  the  handle  is  raised 
so  that  the  prostate  and  bladder  base  are  made  to  protrude  into 
the  wound  (Fig.  230). 

The  prostatic  urethra  is  split  backwards  to  the  region  of  the 


<"■ 


Fig.  230. — Perineal  prostatectomy. 

The    prostatic    retractor   has   been    introduced    and   is   being    pulled   towards  the   surface   and 

forwards.     The  levatores  ani  muscles  have  been  pushed  to  the  sides.     A  vertical  incision  through 

the  prostatic  sheath  has  been  made,  parallel  to  the'prostatic  urethra.     (Young's  operation.) 

vesical  sphincter,  the  sheath  of  the  prostate  is  peeled  ofE  each  lobe, 
and  one  lobe  seized  with  forceps.  This  lobe  is  dissected  off  the 
urethra  with  scissors,  working  outwards,  and  finally  hangs  by  a 


724 


THE  PROSTATE 


[chap. 


pedicle  formed  by  the  prostatic  vessels.  The  pedicle  is  tied  and 
cut  and  the  lobe  removed.  The  same  dissection  is  carried 
out  on  the  other  side ;  an  intravesical  lobe  is  hooked  down 
with  the  finger  and  removed.  The  margins  of  the  urethra  are 
approximated    by     catgut    sutures,    leaving     a     space    through 


Fig.  231. — Perineal  prostatectomy. 

The  right  lobe  is  being  shelled  out  with  the  finger.     (Yoting.) 

which  a  drainage  tube  is  introduced  into  the  bladder,  and  some 
packing  into  the  cavities  from  which  the  prostatic  lobes  were 
removed.  The  structures  of  the  perineum  are  now  brought  to- 
gether with  catgut  sutures.  The  packing  is  removed  in  forty- 
eight  hours,  and  the  perineal  tube  at  the  end  of  a' week,  when 


LVl] 


PERINEAL   PROSTATECTOMY 


725 


a  catheter  is  tied  in  tlu;  uretlira.     Healing  is  complete  in  five  or 
six  weeks. 

Albarran  performs  a  similar  operation,  but  removes  each  pros- 
tatic lobe  from  the  apex  backwards  in  two  or  several  portions. 


Fig.  232. — Perineal  prostatectomy. 

Removal  of  right  lobe  :  cutting  along  the  urethral  aspect.     The  dotted  line  shows  the  incision 
for  removal  of  left  lobe.    {Young.) 

Young  uses  a  V-shaped  incision,  and  introduces  his  prostatic 
retractor  through  an  incision  in  the  membranous  urethra.  This 
part  of  the  operation  is  frequently  attended  with  difficulty.  He 
then  makes  a  longitudinal  incision  1-5  cm.  deep  through  the  whole 


726  THE   PROSTATE  [chap. 

length,  of  the  prostatic  lobe  on  each  side  of  the  urethra,  the  two 
incisions  being  1-8  cm.  apart,  and  leaves  the  vertical  wedge  of 
tissue  between  these  incisions  with  the  view  to  preserving  the 
ejaculatory  ducts.  The  lobes  are  then  dissected  away.  (Figs.  230-2.) 

Perineal  operations  have  also  been  described  by  Nicoll,  Alex- 
ander, Freyer,  and  others,  but  they  require  no  special  notice  here. 

Results  of  perineal  prostatectomy. — Young  shows  a  mortality  of 
3-7  per  cent,  in  450  cases.  Other  observers  are  less  fortunate. 
Watson  found  the  mortality  6-2  per  cent.,  Proust  5-8  per  cent., 
and  Legueu  collected  1,026  cases  with  a  mortality  of  8  per  cent. 

The  late  results  show  a  considerable  proportion  of  cases  of 
urinary  fistula ;  Judd  found  6  in  a  series  of  323  cases.  Inconti- 
nence of  urine  may  follow  the  operation.  Of  323  cases  of  perineal 
prostatectomy  performed  at  St.  Mary's  Hospital,  Kochester, 
U.S.A.,  Judd  found  that  7  had  "  some  degree  of  incontinence," 
and  that  in  11  "  the  retentive  power  was  not  strong."  Several 
patients  had  not  good  control  immediately  following  the  opera- 
tion, but  regained  it  in  a  few  weeks.  Recto-urethral  fistula, 
temporary  or  permanent,  is  sometimes  observed.  In  the  usual 
perineal  prostatectomy  the  sexual  powers  are  abolished.  Young's 
operation  endeavours  to  overcome  this  grave  objection.  In  this 
observer's  statistics  59  per  cent,  of  recent  cases  are  stated  to  have 
had  a  complete  return  of  sexual  power,  and  in  75  per  cent,  erections 
returned.  Apparently,  in  the  remainder  the  sexual  function  was 
destroyed. 

Epididymitis  occurs  as  a  complication  during  convalescence 
in  from  10  to  30  per  cent,  of  cases.  Stricture  is  observed  after 
perineal  prostatectomy,  and  necessitates  dilatation  over  long 
periods.  The  operation  is  always  incomplete,  and  recurrence  of 
the  obstruction  due  to  enlargement  of  the  residual  portions  may 
necessitate  suprapubic  prostatectomy. 

Choice  of  method.' — Suprapubic  prostatectomy  can  be  per- 
formed in  all  forms  of  simple  enlargement  of  the  prostate,  while 
perineal  prostatectomy  is  unsuitable  in  cases  where  there  are 
numerous  vesical  calculi,  or  the  intravesical  projection  is  large 
or  the  prostate  of  considerable  dimensions.  It  follows  that  when 
perineal  prostatectomy  is  practised  as  a  routine  method  the  more 
serious  cases  are  submitted  to  the  suprapubic  operation.  The 
mortality  of  suprapubic  prostatectomy  at  the  present  time  varies 
from  4  to  6  per  cent,  for  all  cases,  that  of  perineal  prostatectomy 
from  3-7  to  5-8  per  cent,  for  the  selected  cases  noted  above. 

The  after-results  of  perineal  prostatectomy  are  unsatisfactory 
when  compared  with  those  of  the  suprapubic  operation.  In  the 
perineal  method  urinary  fistulse  are  twice  as  numerous  and  the 


Lvi]  PROSTATECTOMY  :  CHOICE  OF  METHOD  727 

fistula  cannot  be  cured  ))y  operation  ;  recto-perineal  and  rccto- 
urethral  fistula)  occur ;  stricture  is  frequently  observed,  and 
incontinence  of  urine  results  in  a  number  of  cases.  Epididymitis 
complicates  the  perineal  operation  nnich  more  often  than  the 
suprapubic.  The  sexual  function  is  abolished  in  perineal  prosta- 
tectomy unless  a  portion  of  the  prostate  is  left,  as  in  Young's 
operation ;  in  suprapubic  prostatectomy  it  is  completely  pre- 
served in  a  large  proportion  of  cases.  Recurrence  of  the  prostatic 
tumour  has  been  observed  after  perineal  prostatectomy  ;  it  can- 
not occur  in  complete  suprapubic  prostatectomy.  The  convales- 
cence after  suprapubic  prostatectomy  is  longer  than  after  the 
perineal  operation. 

For  simple  enlargement  of  the  prostate  the  complete  supra- 
pubic operation  is  more  widely  applicable,  and  the  results  are 
infinitely  superior  to  those  of  perineal  prostatectomy.  It  should 
therefore  be  the  method  adopted  in  all  cases.  In  the  so-called 
fibrous  enlargement  the  perineal  route  is  preferable,  but  this 
condition  is  a  purely  inflammatory  one,  and  cannot  be  considered 
as  h  type  of  enlargement  of  the  prostate. 

LITERATURE 

Casper,   Vir chows  Arch.,  Ixxvi.  139. 

Ciechanowski,  Anatomical   Researches  on  Prostatic  Hypertro-phy.     Translated  by 

Greene,  1903. 
Daniel,  Brit.  Med.  Journ.,  1904,  ii.  1140. 
Freyer,  Brit.  Med.  Journ.,  July  20,  1901,  and  Oct.,  1912,  p.  868;  Lancet,  1911, 

i.  923.     Surgical  Diseases  of  the  Urinary  Organs.     1908. 
Judd,  Journ.  of  Amer.  Med.  Assoc,  1911,  p.  458. 
Launois,  These  de  Paris,  1885. 
Marion,  XV'*  Sess.  Assoc.  Frang.  d'Urol.,  1911. 
Motz,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1897,  p.  1117. 
Motz  et  Perearnau,  Ann.  d.  Mai.  d.  Org.  Gen.-Urin.,  1905,  ii.  1521. 
Proust,  La  Prostatectomie  dans  r Hypertrophic  de  la  Prostate.     1904. 
Tandler  und  Zuckerkandl,  Folia  Urol.,  1911,  p.  587. 
Walker,  Thomson,  Med.-Chir.  Trans.,  1904,  Ixxxvii.  ;   Brit.  Med.  Journ.,  July  9 

and  Oct.  29,  1904,  Oct.  7,  1905;  Arch,  of  Middx.  Hosp.,  1905,  vol.  iv. ;  Clin. 

Journ.,  July,  1912,  p.  261. 
Ward,  Birmingham  Med.  Rev.,  March,  1908. 
Watson,  Boston  Med.  and  Surg.  Journ.,  1904,  p.  453. 
Young,  Med.  Press  and  Circ,  1911,  p.  148. 

Discussion  at  British  Medical  Association — Brit.  Med.  Journ.,  Nov.  8,  1902. 
Discussion  at  II.  Congress  of  the  International  Association  of  Urology,  London, 

1911. 


CHAPTER  LVII 

ATROPHY  OF  THE  PROSTATE 

Etiology. — Atrophy  of  the  prostate  occurs  under  a  variety  of 
conditions.  Congenital  atrophy  is  strictly  arrest  of  development 
of  the  gland.  It  is  found  in  combination  with  other  congenital 
malformations  of  the  genital  organs,  especially  imperfect  develop- 
ment and  misplacement  of  the  testicles.  When  one  testicle  has 
failed  to  develop  there  may  be  a  corresponding  arrest  of  develop- 
ment in  the  prostatic  lobe  of  the  same  side.  Not  infrequently, 
however,  both  lobes  of  the  prostate  are  fully  developed  when  one 
testicle  is  infantile. 

Castration  before  puberty  results  in  arrested  development  of 
the  prostate  gland.  Castration  after  puberty  is  followed  by  shrink- 
ing and  diminution  in  size  of  the  prostate.  After  removal  of  one 
testicle  the  prostate  may,  however,  remain  for  long  unchanged 
in  size  on  rectal  palpation. 

Castration  was  at  one  time  supposed  to  be  followed  by  diminu- 
tion in  size  or  atrophy  of  the  hypertrophic  prostate,  and  was  prac- 
tised as  a  method  of  treatment  for  this  disease.  It  is  admitted 
that  a  reduction  in  congestion  of  the  organ  is  produced,  but  the 
belief  that  shrinkage  from  atrophy  of  the  enlarged  organ  takes 
place  is  no  longer  held. 

Atrophy  may  follow  inflammatory  diseases  of  the  gland,  such 
as  acute  and  chronic  gonorrhoeal  prostatitis  and  tuberculous 
disease,  or  pressure  from  calculi  or  from  cysts,  and  is  not  infre- 
quently present  in  old-standing  stricture  of  the  urethra  as  a 
result  of  chronic  prostatitis. 

Senile  atrophy  develops  after  the  age  of  50,  and  occasionally 
earlier.  The  average  age  in  13  advanced  cases  under  my  care  was 
61 1  years,  the  youngest  patient  being  52.  The  condition  in  an 
advanced  state  is  comparatively  rare.  According  to  Ciechanowski, 
atrophy  results  from  pressure  caused  by  fibrosis  due  to  peripherally 
distributed  chronic  prostatitis. 

Pathological  anatomy. — In  advanced  cases  the  lobes  are 
reduced  so  as  to  be  hardly  distinguishable.  On  section  a  firm, 
opaque,  white   or   greyish  surface  is  found,  and  traces  of  gland 

728 


CHAP.  Lvii]  ATROPHY  OF  PROSTATE  729 

tissue  cat!  only  be  i'ound  inicroscopicHlly.  Occasionally  small 
cystic  spaces  are  present,  which  may  contain  corpora  amylacea. 
The  muscle  fibres  are  replaced  by  fibrous  tissue.  The  prostatic 
urethra  may  be  tough  and  leathery,  and  fibrous  infiltration  of  the 
tissues  around  the  vesical  orifice  ("  contracture  of  the  neck  of 
the  bladder")  may  be  observed. 

Symptoms.- — Frecpient  micturition  is  the  most  constant  symp- 
tom. It  is  present  both  day  and  night,  and  amounts  to  six  or 
eight  times  during  the  day  and  twice  or  thrice  at  night.  Occa- 
sionally there  is  great  urgency  and  constant  desire  to  micturate. 
Nocturnal  enuresis  is  not  uncommon,  and  in  a  few  cases  complete 
incontinence  develops.  Difficult  micturition,  or  gradual  or  sudden 
onset,  is  often  present. 

The  stream  is  poor  and  may  be  reduced  to  a  dribble.  Com- 
plete retention  is  rare. 

In  the  early  stage  and  in  moderate  degrees  there  is  no  re- 
sidual urine,  but  later  several  ounces  of  urine  may  remain  after 
micturition,  and  occasionally  the  bladder  is  chronically  distended. 
The  urine  may  be  clear,  but  usually  contains  evidence  of  chronic 
urethral  or  vesical  inflammation. 

An  instrument  may  pass  easily  into  the  bladder,  and  the  total 
length  of  the  urethra  is  found  to  be  reduced.  In  some  cases  there 
is  obstruction  at  the  internal  meatus,  due  to  fibrous  induration 
of  this  portion  of  the  canal  or  to  a  fold  of  mucous  membrane. 

On  rectal  examination  the  prostate  is  greatly  reduced  in  size, 
and  is  flat  and  smooth,  with  an  ill-defined  outline,  or  the  finger 
may  fail  to  detect  any  remains  of  the  gland.  The  membranous 
and  prostatic  portions  of  the  urethra  can  be  felt,  and  some- 
times the  seminal  vesicles,  but  the  lobes  of  the  prostate  are 
wanting. 

Diagnosis. — The  symptoms  may  closely  resemble  those  of 
hypertrophy  of  the  prostate,  but  on  rectal  examination  the  atrophy 
is  readily  recognized. 

In  chronic  periprostatitis  the  prostate  is  obscured  on  rectal 
palpation,  but  here  all  the  structures  on  the  anterior  wall  of  the 
rectum,  such  as  the  seminal  vesicles,  membranous  and  prostatic 
urethra,  are  also  hidden.  Examination  with  a  sound  in  the  urethra 
assists  the  diagnosis.  In  atrophy  of  the  prostate  it  is  felt  in  the 
prostatic  urethra  ;  in  chronic  periprostatitis  it  is  felt  with  difficulty 
or  not  at  all.  • 

The  "  atrophic  "  type  of  carcinoma  of  the  prostate  may  give 
rise  to  difficulty  in  diagnosis  from  simple  atrophy  of  the  organ. 
In  the  malignant  growth  the  gland,  although  small  and  flat,  is 
hard  and  fixed,  and  a  sound  in  the  prostatic  urethra  cannot  be 


730  THE   PROSTATE  [chap,  lvii 

felt  from  the  rectum.  The  early  appearance  of  metastatic  growths 
will  put  an  end  to  any  doubt. 

Treatment. — When  possible,  the  cause,  such  as  stricture  or 
prostatic  calculus,  is  removed.  The  use  of  the  catheter  is  necessary 
when  there  is  residual  urine  or  complete  retention. 

Incontinence  of  urine  may  necessitate  the  wearing  of  a  rubber 
urinal.  Barth  recommends  perineal  prostatectomy,  and  holds 
that  good  results  follow  the  removal  of  scar  tissue  from  around 
the  prostatic  urethra.  The  regular  passage  of  large  metal  instru- 
ments is  of  benefit,  and  where  there  is  obstruction  at  the  vesical 
outlet  good  results  may  be  obtained  by  incision  and  dilatation 
of  the  internal  meatus  through  a  suprapubic  cystotomy  wound. 
Perineal  prostatotomy  has  also  proved  useful,  and  Bottini's  galvano- 
caustic  operation  has  been  recommended. 

LITERATURE 

Barth,  Arch.  /.  Bin.   Chir.,  1911,  Heft  3. 

Englisch,  Zeits.  f.  Heilk.,  1901,  Heft  12. 

Fuller,  Amer.  Journ.  of  Med.  Sci.,  1897,  p.  440. 

Launois,  Ann.  d.  Mai-  d.  Org.  Gen.-Urin.,  1894,  p.  721. 

Rorig,    Centralhl.  f.  d.  Krankh.  d.  Ham-  u.  Sex.- Org.,  1903,  S.  243. 

Strauch,   Centralbl.  /.  d.  Krankh.  d.  Ham-  u.  Sex.-Org.,  1894,  S.  227. 


CHAPTER  LVIII 
MALIGNANT  DISEASE  OF  THE  PROSTATE 

The  ratio  of  cancer  of  the  prostate  to  other  forms  of  cancer  was 
2-3  per  1,000  in  6,732  cases  of  cancer  at  the  Middlesex  Hospital. 
The  relative  frequency  of  malignant  disease  of  the  prostate  in 
242  consecutive  cases  of  prostatic  enlargement  under  my  care 
was  16-5  per  cent. 

Etiology. — There  is  no  certain  knowledge  as  to  the  cause  of 
prostatic  carcinoma.  Calculus  of  the  prostate  is  a  rare  precancerous 
condition.  Malignant  disease  rarely  develops  in  a  prostate  the 
seat  of  hypertrophy  or  simple  enlargement.  A  number  of  cases 
are,  however,  on  record  where  examination  of  a  specimen  of 
enlarged  prostate  after  enucleation  showed  undoubted  malignant 
characters  in  some  part  of  it.  Albarran  and  Halle  have  stated 
that  20  per  cent,  of  cases  of  supposed  simple  enlargement  of  the 
prostate  are  malignant.  The  proof  of  malignancy  in  these  cases, 
however,  rested  upon  epithelial  changes  the  significance  of  which 
is  open  to  doubt. 

Pathological  anatomy  and  histology. — Carcinoma  is  the 
common  form  of  malignant  disease  of  the  prostate,  while  sarcoma 
is  rare. 

Carcinoma  occurs  most  frequently  between  the  ages  of  50  and 
70  ;  the  average  in  40  cases  was  65  years.  In  one  patient  the 
symptoms  commenced  at  the  age  of  44,  and  in  another  at  48. 
The  enlargement  may  be  slight,  and  von  Eecklinghausen  pointed 
out  that  the  cancerous  prostate  might  be  scarcely  enlarged,  or 
even  smaller  than  the  normal  gland.  In  the  greater  number  of 
cases,  however,  the  organ  is  considerably  enlarged,  and  it  may 
reach  very  large  proportions.  It  is  hard,  and  may  be  cartilaginous 
to  the  touch.  Less  frequently  it  forms  a  soft,  very  rapidly  grow- 
ing tumour.  On  section  it  presents  a  thick,  fibrous  stroma  with 
whitish  nodules,  or  it  may  be  hard  and  scirrhous  throughout. 
The  commonest  form  retains  the  outline  of  the  prostate,  but  there 
may  be  a  diffuse  carcinomatous  infiltration  of  the  areolar  tissue 
of  the  pelvis,  matting  the  pelvic  organs  together  in  an  inseparable 
mass  ("  carcinose  'prostato-pelvieme  diffuse  " — Guy  on). 

731 


732  THE   PROSTATE  [chap. 

The  structure  of  the  majority  of  carcinomas  of  the  prostate 
is  a  small  round  or  polygonal  type  of  spheroidal-celled  carcinoma 
(Fig.  233),  and  they  are  peculiar  in  that  the  stroma  is  infiltrated 
with  fine  rows  of  cells  or  small  isolated  clumps.  The  entire  tumour 
may  thus  in  the  gross  specimen  appear  peculiarly  fibrous,  while 
under  the  microscope  it  is  strikingly  rich  in  cellular  elements. 
Even  in  the  common  spheroidal-celled  carcinoma  there  are  certain 
parts  where  there  is  a  development  of  cylindrical-celled  adeno- 


■^  y^yr-yf^^-- 


h 


^."'AW^' 


/^  '■    Fo^n-'  •,,^ '.,-:'  >>'?.'     ,' 


Fig.  233. — Carcinoma  of  prostate. 

carcinoma.  In  other  cases  the  structure  is  largely  that  of  a  cylin- 
drical-celled adeno-carcinoma.  In  these  some  parts  may  reproduce 
the  structure  of  a  spheroidal-celled  carcinoma. 

The  direction  of  spread  may  be  towards  the  bladder  cavity, 
into  which  the  carcinoma  fungates.  Clinically  this  form  is  relatively 
uncommon,  but  it  frequently  occurs  in  later  stages,  and  is  found  in 
a  large  proportion  of  cases' post  mortem  (57  in  100  cases — Kauff- 
mann ;  80  per  cent,  in  17  cases — Thomson  Walker).  Spread 
along  the  outer  surface  of  the  bladder  is  common,,  the  growth 
surrounding  the  seminal  vesicles  and  lower  ends  of  the  ureters 


iviii]     MALIGNANT   DISEASE   OF   PROSTATE      733 

and  occluding  the  latter.  The  growth  may  also  spread  laterally 
in  the  areolar  tissue  of  the  pelvis,  obliterating  the  lateral  sulcus 
on  each  side  of  the  prostate.  In  a  few  cases  the  growth  spreads 
towards  the  rectum,  and  may  cause  ulceration  of  the  rectal  mucous 
membrane.  More  frequently  it  spreads  round  the  outside  of  the 
rectum,  narrowing  the  limien.  The  pelvic  peritoneum  may  be 
involved.  Deposit  in  lymph-glands  takes  place  comparatively 
early,  those  along  the  internal  iliac  vessels  being  first  affected. 
The  lowest  lymph  nodules  of  this  chain  lie  in  a  band  which  passes 
out  from  the  base  of  the  prostate  on  each  side  and  can  be  felt 
with  the  finger  in  the  rectum.  The  inguinal  glands  are  involved 
in  16  per  cent,  of  cases.  The  liver,  lungs,  kidneys,  suprarenal 
glands,  pancreas,  and  less  frequently  other  organs,  may  be  the 
seat  of  metastatic  deposit.  There  is  a  peculiar  tendency  for  pros- 
tatic carcinoma  to  produce  metastases  in  the  bony  skeleton, 
forming  osteoplastic  nodules  or  widespread  infiltration  (70  per 
cent. — Kauffmann).  The  vertebrae  are  most  frequently  affected, 
and  then  the  femur,  pelvis,  ribs,  skull,  sternum,  humerus,  fibula, 
tibia,  radius,  and  ulna. 

Sarcoma  of  the  prostate  is  rare.  It  may  occur  at  any  age, 
but  in  most  of  the  recorded  cases  the  age  has  been  under  10  years, 
and  the  tumours  have  grown  rapidly  and  attained  a  large  size. 
The  usual  forms  are  round-  and  spindle-celled,  but  4  cases  of 
rhabdo-myo-sarcoma  (Kauffmann  3,  Greig  1)  are  on  record. 

Symptoms. — Difiicult  micturition  is  the  most  frequent  (92 
per  cent.)  and  often  the  first  (55  per  cent.)  symptom.  The  onset 
is  gradual.  The  stream  is  delayed  and  is  small,  and  the  projection 
feeble,  and  there  is  after-dribbling.  With  this  there  may  be  one 
or  several  attacks  of  retention,  and  eventually  the  patient  may 
become  partly  or  completely  dependent  on  the  catheter.  In  other 
cases  the  onset  of  difficulty  is  sudden,  and  there  may  be  an  initial 
attack  of  complete  retention. 

Frequent  micturition  occurs  in  87*5  per  cent,  of  cases,  but  is 
rarely  the  first  symptom.  The  increased  frequency  occurs  during 
the  day,  and  it  is  also  necessary  to  pass  water  at  night,  usually 
at  equal  intervals  of  two  or  three  hours. 

In  a  few  cases  there  is  dribbling  of  urine  from  a  bladder  which 
is  not  distended.  In  these  the  growth  has  spread  widely  and  the 
whole  bladder  base  is  rigid,  so  that  the  internal  meatus  is  open 
and  rigid  and  control  by  the  sphincter  is  lost. 

Pain  occurs  in  72-5  per  cent,  of  cases,  and  is  sometimes  the 
initial  symptom.  Tlie  characteristic  pain  of  prostatic  carcinoma 
is  unconnected  with  micturition  or  with  obstruction  to  the  flow 
of  urine.     It  is  felt  in  one  or  several  of  the  following  situations — 


734  THE   PROSTATE  [chap. 

viz.  the  penis  or  urethra,  rectum,  anus,  sacrum,  sacro-iliac  syn- 
chondrosis, hip-joints,  suprapubic  region,  perineum,  groins,  thighs, 
legs,  testicles.  The  pain  is  a  dull,  constant  aching,  which  persists 
over  months  or  years  ;  it  is  miconnected  with  micturition,  defaeca- 
tion,  or  movement,  and  is  little  affected  by  drugs.  It  may  take 
the  form  of  sciatica,  which  may  be  the  prominent  symptom,  while 
prostatic  symptoms  are  insignificant. 

Hsematuria  is  absent  in  the  majority  of  cases.  When  it  is 
present  (12-5  per  cent.)  the  urine  may  be  bright  or  dark,  and  is 
usually  in  small  quantity. 

Emaciation  is  late  and  usually  slight.  There  may  be  emacia- 
tion from  urinary  septicaemia  which  is  not  directly  due  to  the 
malignant  growth. 

Intestinal  symptoms  are  comparatively  frequent.  There  is 
constipation,  and  in  the  later  stages  intestinal  obstruction  may 
supervene.  Occasionally  where  the  growth  surrounds  the  rectum 
the  symptoms  of  intestinal  obstruction  occur  comparatively  early 
and  overshadow  the  urinary  symptoms,  leading  to  a  diagnosis  of 
malignant  disease  of  the  rectum. 

On  rectal  examination  the  prostate  is  hard,  irregular,  and 
fixed.  The  malignant  infiltration,  whether  in  nodules  or  diffuse, 
is  stony-hard.  Small  points  or  ridges  may  appear  in  the  rectal 
surface,  as  hard  and  sharp  as  the  edge  of  a  flint. 

Occasionally  a  malignant  prostate  is  small  and  tough,  and 
rarely  it  forms  a  large,  soft  tumour.  The  most  frequent  form  is 
a  moderate  .enlargement  made  up  of  numerous  hard  nodules 
separated  by  clefts  and  fissures,  with  at  some  part  a  hard,  sharp 
ridge  or  point,  which  appears  to  project  through  the  rectal  wall. 
In  a  few  cases  (20  per  cent.)  the  gland  retains  its  normal  contour 
and  is  enlarged,  smooth,  and  stony- hard  throughout.  A  single 
nodule  of  malignant  growth  may  be  buried  in  one  lobe. 

In  advanced  cases  the  prostate  projects  into  the  rectum  as  a 
large  mass  spreading  over  and  surrounding  the  seminal  vesicles 
and  infiltrating  the  bladder  base  beyond  the  reach  of  the  finger. 
This  upward  spread  may  be  more  marked  on  one  side.  Lateral 
spread  of  the  growth  fills  up  the  sulcus  on  each  side  of  the  pros- 
tate, so  that  the  gland  on  rectal  palpation  appears  to  be  diminished 
in  size.  Spread  round  the  rectum  may  form  a  thick  ring  which 
contracts  the  rectal  lumen  and  is  occasionally  mistaken  for  a  new 
growth  of  the  rectum. 

Enlarged  lymph-glands  are  first  felt  as  small  shotty  nodules 
in  the  band  which  passes  outwards  on  each  side  at  the  base  of 
the  prostate. 

On  passage  of  an  instrument  there  is  obstruction  in  the  pros- 


Lviii]    MALIGNANT  PROSTATE:  DIAGNOSIS       735 

tatic  urethra,  and  the  tough  character  of  the  gland  may  be  felt. 
Occasionally  the  prostatic  urethra  becomes  distorted  by  the 
growth,  so  that  the  obstruction  lies  at  the  membranous  urethra. 
On  cystoscopy  the  gland  projects  into  the  bladder  only  to  a  small 
extent.  The  edge  of  the  internal  meatus  is  usually  irregular  and 
opaque ;  rarely  the  growth  may  be  seen  infiltrating  the  bladder 
mucous  membrane. 

Diagnosis. — Malignant  growths  of  the  prostate  most  closely 
resemble  stricture  of  the  urethra  in  their  symptomatology,  and 
stone  in  the  prostate  on  rectal  examination ;  but  simple  enlarge- 
ment and  atony  from  disease  of  the  spinal  cord  may  also  give  rise 
to  difficulty. 

In  sricture  of  the  urethra  pain  and  emaciation  are  absent, 
and  the  symptoms  commence  at  a  much  earlier  age.  The  usual 
age  at  which  symptoms  of  stricture  appear  is  between  20  and  40  ; 
the  average  age  in  malignant  growth  of  the  prostate  is  65.  The 
use  of  the  urethroscope,  the  passage  of  a  large-sized  bougie,  and 
rectal  examination  will  differentiate  between  these  diseases.  In 
stone  in  the  prostate  there  is  frequently  an  abundant  pyuria  and 
the  grate  of  the  stone  ngiay  be  felt  on  passing  a  metal  instrument, 
if  the  cavity  containing  it  communicates  with  the  urethra.  On 
rectal  examination  stone  forms  a  single  mass,  even  where  a  number 
of  stones  are  present,  while  the  malignant  prostate  has  a  number 
of  irregularly  shaped  nodules  with  sulci  between,  and  ridges  and 
sharp  points  on  the  surface.  The  prostate  is  usually  movable  in 
stone,  and  crepitation  is  characteristic  of  a  collection  of  prostatic 
calcrdi.  The  latter  symptom  is  easily  overlooked,  and  should  be 
carefully  searched  for  in  doubtful  cases.  The  X-rays  give  a  dark 
shadow  in  the  position  of  the  prostate  in  stone,  and  no  prostatic 
shadow  in  carcinoma.  In  sim'ple  enlargemen'  the  symptoms  are 
usually  those  of  irritation  rather  than  obstruction  in  the  early 
stage ;  the  prostatic  type  of  nocturnal  frequency  is  typical  of 
simple  enlargement.  Pain  is  absent,  and  rectal  examination  dis- 
closes an  elastic,  sometimes  firm,  but  always  movable  enlargement 
of  the  gland,  while  the  cystoscope  reveals  a  rounded  projection  of 
one  or  both  lobes.  Haematuria  is  more  frequent  in  simple  than  in 
malignant  disease  of  the  prostate.  Bladder  atony  is  diagnosed  by 
examination  of  the  spinal  reflexes  and  exclusion  of  obstruction  of 
the  urethra.  The  cystoscope  shows  a  trabeculated  bladder  of  the 
atrophic  type  in  atony  from  spinal  disease  (p.  533). 

Treatment.  1.  Palliative. — The  majority  of  cases  have  pro- 
gressed too  far  when  the  diagnosis  is  made  for  any  radical  opera- 
tion to  be  considered.  Treatment  then  consists  in  relieving  symp- 
toms.    The  administration  of  ergot   (liquid  extract,    15  minims) 


736  THE   PROSTATE  [chap. 

and  strychnine  (liquor,  5  minims)  increases  the  contractile  power 
of  the  bladder  and  assists  in  the  expulsion  of  urine.  The  passage 
of  large  metal  instruments  into  the  bladder  at  intervals  of  a  week 
or  a  fortnight  gives  much  relief.  In  the  majority  of  cases  this 
is  unattended  by  any  danger  of  bleeding ;  but  when  heematuria 
is  already  a  feature  of  the  case,  dilating  instruments  should  be 
avoided.  With  increasing  obstruction  and  retention  of  urine 
the  catheter  may  become  necessary.  The  passage  of  a  catheter 
is  usually  difficult,  and  the  urethra  may  become  so  distorted  that 
self-catheterization  is  impossible.  In  such  cases  permanent  supra- 
pubic cystotomy  becomes  necessary.  The  bladder  is  exposed  by 
a  vertical  median  suprapubic  incision,  which  cuts  through  the 
rectus  sheath,  and  separation  of  the  recti  muscles.  The  bladder 
is  drawn  up  to  the  level  of  the  skin,  opened,  and  stitched  to  the 
skin  with  catgut,  and  the  recti  muscles  and  sheath  are  closed 
above  it.  In  doing  this  the  bladder  should  be  drawn  through  the 
rectus  muscle  on  one  side  so  as  to  obtain  some  amount  of  valve 
action  (p.  549).  A  tube  is  placed  in  the  bladder  through  the  cyst- 
otomy wound  and  retained  there  until  the  opening  has  contracted 
down  to  the  size  of  a  No.  12  B.  catheter,  when  an  apparatus  is  fixed 
consisting  of  a  metal  plate  retained  in  position  by  elastic  straps 
and  carrying  in  a  tube  a  No.  12  E.  rubber  catheter,  which  lies  in 
the  suprapubic  wound  and  ends  in  a  rubber  urinal  strapped  to 
the  thigh.  For  the  pain,  phenacetin  (10  gr.),  antipyrin  (10  gr.), 
caffeine  (3  gr.),  or  aspirin  (10  gr.)  should  be  given  in  cachet.  Should 
these  fail,  opium  or  morphia  in  some  form  should  be  allowed. 
The  injection  of  20  minims  of  tincture  of  opium  into  the  rectum 
sometimes  gives  greater  relief  than  hypodermic  administration  of 
morphia.  Radium-therapy  has  been  used  in  several  cases  and  has 
given  encouraging  results,  but  at  the  present  it  is  still  under  trial. 
2.  Operative  treatment. — Only  those  cases  in  which  the 
growth  is  confined  to  the  prostate  should  be  submitted  to  radical 
operation,  and  the  patient  must  be  sufficiently  strong  to  withstand 
a  severe  operation.  Many  operative  procedures  have  been  recorded, 
but  it  is  mmecessary  to  describe  them  here. 

Suprapubic  operations. — These  consist  in  enucleation  of  the 
malignant  prostate  with  the  finger  after  Freyer's  method  (p.  709). 
In  certain  cases  it  is  possible  to  enucleate  a  malignant  prostate  by 
this 'method.  These  are  cases  of  adenomatous  enlargement  which 
have  become  malignant.  In  one  type  of  case  the  enlargement 
appears  to  be  benign  and  is  easily  removed,  and  the  presence  of 
malignant  degeneration  is  only  discovered  on  histological  examin- 
ation. In  another  type  some  part  of  an  adenomatous  prostate 
can  be  felt  to  be  tough  and  firmer  than  the  rest  of  the  gland.     On 


Lviii]     MALIGNANT  PROSTATE  :  OPERATION     737 

enucleation  the  prostate  is  found  to  be  densely  adherent  to  its 
sheath  at  one  part,  and  after  enucleation  a  dense  leathery  plaque 
remains  adherent  to  the  wall  of  the  cavity. 

The  great  majority  of  cases  of  malignant  prostate  are,  however, 
quite  unsuited  for  suprapubic  enucleation.  On  opening  the  bladder 
the  finger  feels  the  base  tough  and  adherent  to  the  underlying 
prostate.  There  is  much  difficulty  in  commencing  the  enucleation 
in  the  region  of  the  internal  meatus,  and  when  it  is  begun  there 
is  no  line  of  cleavage  into  which  the  finger  can  sink.  Eventually 
one  or  two  portions  of  tissue  of  tough,  indiarubber-like  consist- 
ence are  removed,  together  with  the  wall  of  the  prostatic  urethra. 
A  conical  cavity  is  left,  with  tough,  irregular  walls.  There  is  little 
bleeding.  The  result  of  such  operation  is  rapid  recurrence,  very 
frequently  with  sepsis  superadded,  and  the  period  of  existence  is 
probably  shorter,  and  certainly  less  comfortable,  than  it  would 
have  been  without  operation. 

In  yet  another  type  one  lobe  is  malignant  and  adherent  while 
the  other  is  adenomatous.  The  adenomatous  lobe  shells  out. 
leaving  the  tough,  malignant  lobe  adhering  to  the  wall  of  the 
cavity.  Some  cases  of  so-called  fibrous  prostate  are  malignant  in 
nature.  Only  shreds  of  indiarubber-like  consistence  can  be  re- 
moved by  this  method,  and  the  operation  is  entirely  unsuitable 
for  such  cases. 

Perineal  operations. — i.  Prostatectomy  may  be  performed  in 
the  same  manner  as  for  the  perineal  removal  of  benign  enlarge- 
ment of  the  prostate.  It  is  wise  in  these  cases  to  remove  the 
sheath  with  the  prostate,  and  to  dissect  the  prostatic  tissue  from 
the  urethra  as  thoroughly  as  possible. 

ii.  Young's  operation  consists  in  the  removal  of  the  prostate 
and  its  sheath,  the  prostatic  urethra,  the  portion  of  bladder  wall 
overlying  the  prostate,  the  seminal  vesicles,  and  the  lower  end 
of  the  vasa  deferentia.  This  is  carried  out  by  an  inverted  V  perineal 
incision  and  exposure  of  the  membranous  urethra,  which  is  opened 
on  a  grooved  staff.  A  Young's  prostatic  depressor  is  now  intro- 
duced and  the  posterior  surface  of  the  gland  freely  exposed.  The 
membranous  urethra  is  cut  across,  and  the  apex  of  the  prostate 
depressed  and  pulled  downwards  and  separated  from  the  posterior 
surface  of  the  pubic  symphysis.  A  transverse  incision  is  now 
made  through  the  anterior  bladder  wall  at  the  base  of  the  pros- 
tate, and  by  further  depressing  the  prostate  this  can  be  extended 
laterally  so  as  to  expose  the  upper  surface  of  the  gland,  covered 
by  bladder  base.  A  transverse  incision  is  made  immediately  in 
front  of  the  ureteric  orifices,  and  the  bladder  wall  carrying  these 
is  pushed  back,  exposing  the  seminal  vesicles  and  vasa  deferentia. 


738  THE   PROSTATE  [chap,  lviii 

The  latter  are  cut  across,  and  the  prostate  is  now  free.  The  open- 
ing in  the  bladder  wall  is  closed  with  catgut  sutures  from  behind 
forwards,  leaving  a  small  opening  at  the  anterior  angle,  and  this 
is  brought  down  and  united  to  the  stump  of  the  membranous 
urethra.  The  perineal  structures  are  united,  a  rubber  drain  is 
placed  in  the  wound,  and  a  catheter  tied  in  the  urethra.  At  first 
there  is  complete  incontinence,  and  a  rubber  urinal  is  worn  ;  but 
if  care  is  exercised  almost  perfect  control  is  regained  by  the  action 
of  the  compressor  urethrse,  and  every  care  should  be  taken  to 
preserve  this  muscle  as  far  as  possible  during  the  operation. 

r        Results. — After    suprapubic  enucleation  recurrence  is  usually 
rapid,  few  of  the  patients  living  longer  than  eighteen  months  tci- 
two  years.     Perineal  prostatectomy  gives  temporary  relief  from 
symptoms,  but  the  growth  recurs  in  from  one  to  two  years. 

Of  3  of  my  patients  operated  on  by  Young's  method,  2 
died  of  recurrence  two  years  and  the  third  three  and  a  half  years 
after  the  operation.  Young  has  performed  the  operation  6 
times,  and  2  of  his  patients  are  alive  and  apparently  well,  one 
six  years  after  the  operation  and  the  other  two  years. 

LITERATURE 

Adenot,  A?in.  d.  Mai.  d.  Org.  Gen.-  JJrin.,  1901,  p.  596. 

von  Frisch,  Krankheiten  der  Prostata.     1899. 

Fuller,   Journ.  Cutan.  and  Gen.-  Urin.  Dis.,  1898,  p.  581. 

Greene,  N.  Y.  Med.  Journ.,  1903,  p.  285. 

Grelg,  Brit.  Journ.  Child.  Dis.,  May,  1908. 

Harris,  Ann.  Surg.,  1902,  p.  509. 

Motz  et  Majewski,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1907,  i.  161. 

Oraison,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1903,  p.  641. 

Petit,  These  de  Paris,  1902. 

Pousson,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1904,  p.  881. 

Proust,   Prostatectoynie  Perineale  totale.     1900. 

Socin  und  Burckhardt,  Krankheiten  der  Prostata.     1902. 

Walker,  Thomson,  Arch,  of  Middx.  Hosp.,  1905,  vol.  v.  ;    Lancet,  April  11,  1908  ; 

Pract.,  Feb.,   1908. 
Young,    Johns  Hopkins  Hosp.   Repts.,   1906,  vol.  xiv.  ;    lie  Congres  de  I'Assoc, 

Internat.  d'Urol.,  London,  1911. 
Zuckerkandl,  Wien.  med.  Presse,  1889,  Nr.  7,  p.  19. 


CHAPTER  LIX 
CALCULUS  OF  THE  PROSTATE 

Prostatic  calculi  occur  in  middle  life  and  old  age.  The  average 
in  29  cases  under  my  care  was  50-6  years.  The  oldest  patient 
was  72,  the  youngest  21  years. 

Etiology. — There  are  three  chief  classes  of  prostatic  calculi  : 

1.  Calculi  originating  in  the  substance  of  the  prostatic  gland. 

2.  Calculi  in  the  prostatic  urethra. 

3.  Calculi    in    pouches    communicating    with    the    prostatic 

urethra . 
L  Small  bodies  varying  in  size  from  a  grain  of  sand  to  a  millet- 


Fig.  235. — True  prostatic 

calculi    removed    from 

.  .  .  prostate, 

l^ig.  <i34. — Collection  of  true  prostatic 

calculi  removed  from  prostate. 

seed  are  found  in  the  prostate  at  any  age  after  puberty  ;  they  are 
larger  and  more  numerous  in  old  age.  They  are  round,  oval,  or 
polygonal  (Figs.  234,  235)  ;  at  first  thev  are  colourless,  then 
yellow,  bro-wn,  and  finally  black.  The  nucleus  is  homogeneous  or 
granular,  and  shows  remains  of  cell  nuclei,  and  the  periphery  is 
laminated.     These  bodies  are  named  corpora  amylacea,  from  their 

739 


740 


THE  PROSTATE 


[chap. 


starch-like   consecutive   laminations,    and   from   taking   a   violet 
colour  on  the  addition  of  potassium  iodide. 

In  their  composition  two  substances  are  present,  an  albuminoid 
and  lecithin,  the  latter  being  a  constituent  of  the  prostatic  secre- 
tion. The  bodies  may  increase  in  volume  and  form  split-pea-sized 
calculi  scattered  throughout  the  substance  of  one  or  both  lobes, 
or  a  number  may  become  cemented  together  to  form  irregular 
or  nodular  concretions  the  size  of  a  split  pea  or  even  larger ;  or 
a  number  of  small,  polished,  round,   or  faceted  black  prostatic 


Fig.  236. — Four  calculi, 
identical  in  size  and 
shape,  removed  from 
prostate  at  intervals  of 
12  or  18  months. 


Fig.  237. —  Lateral  view 
of  the  same  calculi  as 
in  Fig.  236. 


concretions,  resembling  small  gall-stones,  collect  in  a  cavity  in 
the  substance  of  the  prostate. 

A  small  prostatic  calculus  of  this  nature  may  receive  phos- 
phatic  deposits  and  form  the  nucleus  of  a  large  phosphatic 
calculus.  These  calculi  are  composed  of  phosphates,  and  they 
contain  a  considerable  proportion  of  organic  matter  and  calcium 
carbonate. 

2.  Calculi  in  the  prostatic  urethra  are  secondary,  and  are  derived 
from  the  bladder  or  kidneys,  having  the  composition  of  vesical 
and  renal  calculi.  By  phosphatic  deposit  the  calculus  increases 
in  size  and  eventually  projects  through  the  vesical  sphincter  into 


LIX] 


CALCULUS  OF  PROSTATE 


741 


the  bladder.     The  portion  exposed  to  the  urine  in  tiie  })hidder 
increases  rapidly,  and  a  mushroom  form  is  produced. 

3.  Calculi  in  'pouches  coynmunicalituj  ivith  the  'prostatic  urethra 
are  formed  by  the  deposit  of  phosphatic  salts  from  the  urine.  The 
origin  of  these  pockets  is  sometimes  obscure,  but  occasionally  a 
history  of  the  rupture  of  a  prostatic  abscess  into  the  urethra  can 
be  obtained. 

Such  a  cavity  acts  as  a  mould,  and  if,  after  removal  of  the 
calculus,  the  pocket  is  not  destroyed  a  calculus  again  forms,  and 
the  successive  calculi  resemble  each  other  to  the  smallest  detail 
(Figs.  236,  237).  The  shape  of  these  calculi  conforms  to  that 
of  the  cavity.  They  usually  project  from  it  into  the  urethra, 
and  a  gutter  is  found  on  the 
urethral  portion  (Fig.  238), 
which  is  miited  with  the  pros- 
tatic portion  by  a  neck.  These 
calculi  occur  most  frequently 
in  young  men. 

When  calculi  are  present  in 
the  prostate  the  prostatic  tissue 
becomes  fibrous,  and  is  re- 
duced, in  large  calculi,  to  a 
mere  shell  which  is  adherent 
to  its  sheath. 

Symptoms. — These  are  fre- 
quently obscure.  Pain  is  usually 
present ;    it  may  be    felt  only 
during    and    after    micturition, 
and  is  sharp  and  pricking ;  or 
it   is    a    constant    aching,    un- 
connected   with  micturition  and    sometimes    reHeved    by  it,   re- 
ferred to  the    rectum,  testicle,  perineum,  groin,  or   thigh.      The 
pain  is  usually  aggravated  by  defaecation.     Hsematuria  is   often 
present,  as  an  occasional  attack  or  as  slight  terminal  hsematuria. 

In  many  cases  there  is  purulent  urethral  discharge,  which  may 
be  copious.  Frequent  micturition  is  a  constant  symptom,  and  is 
present  day  and  night.  Small  stones  may  be  passed  when  a  col- 
lection occupies  a  pocket  commmiicating  with  the  urethra.  As 
many  as  twenty  calculi  may  be  passed  in  this  way.  Difl&cult 
micturition  and  occasionally  retention  of  urine  are  observed. 

When  the  calculi  are  buried  in  the  substance  of  the  prostate 
their  discovery  may  be  accidental.  The  symptoms  are  usually 
those  of  posterior  urethritis  or  chronic  prostatitis.  When  the 
stone  lies  in  the  prostatic  urethra  or  in  a  cavity  communicating 


Fig.  238. — Prostato-urethral  cal- 
culus, showing  vertical  groove 
along  which  urine  passed. 


742  THE   PROSTATE  [chap. 

witK  it  there  are  pyuria,  frequent  and  difficult  micturition,  and 
sometimes  retention. 

On  rectal  examination  a  small  collection  of  prostatic  calculi  is 
felt  as  a  nodule  in  one  lobe  of  the  prostate. 

A  large  stone,  or  a  collection  of  stones,  forms  a  mass  in  one 
or  both  lobes.  The  prostate  is  tender  on  palpation.  Crepitation 
is  usually  present,  and  is  elicited  by  pressure  with  the  finger-pulp 
on  the  hard  mass.  It  closely  resembles  the  sensation  given  to 
the  finger  by  emphysema  of  the  skin  or  by  teno-synovitis. 

Diagnosis. — The  passage  of  a  sound  gives  no  information  if 
the  calculus  is  buried  in  the  substance  of  the  gland ;  but  if  the 
stone  lies  in  the  prostatic  urethra  or  in  a  pocket  communicating 
with  it,  the  metal  instrument  grates  on  its  surface.  When  the 
stone  is  small  and  free  in  the  urethra  the  sound  may  push  it  back 
into  the  bladder,  and  a  second  attempt  may  fail  to  find  it  until 
the  bladder  cavity  is  sounded. 

On  rectal  examination  a  small  collection  of  calculi  may  resemble 
inflammatory  thickening  in  chronic  prostatitis,  or  a  tuberculous 
nodule.  Crepitation  may  be  obtained  even  in  a  small  collection 
of  calculi.  The  X-rays  give  a  definite  shadow  in  prostatic  calculi 
(Plate  42),  and  none  in  chronic  prostatitis  or  tuberculous  nodules. 
In  tuberculous  disease  there  are  frequently  nodules  in  the  epi- 
didymis. The  nodules  of  chronic  prostatitis  are  rarely  so  definite 
as  to  lead  to  a  mistake  in  diagnosis. 

Larger  calculi  may  be  confused  with  a  malignant  growth  of 
the  prostate.  In  malignant  growth  there  are  frequently  multiple 
hard  nodules,  with  deep  sulci  between  ;  a  hard,  sharp  ridge  or 
point  projecting  on  the  rectal  surface  of  the  prostate  is  part  of  a 
malignant  growth  and  not  a  calculus. 

The  gland  is  almost  invariably  fixed  in  carcinoma,  but  movable 
in  calculus.  Exceptions  to  this,  however,  occur.  Crepitation  is 
characteristic  of  calculus.  The  X-rays  throw  a  heavy  shadow 
in  calculus,  but  no  shadow  in  the  prostatic  area  in  malignant 
disease. 

Treatment. — The  method  of  removal  of  the  calculus  varies 
in  different  cases. 

If  the  calculus  is  in  the  prostatic  urethra  and  does  not  project 
into  the  bladder,  the  membranous  urethra  should  be  opened'  by  a 
median  perineal  incision,  and  the  stone  removed  by  the  finger 
aided  by  a  suitable  stone  scoop.  In  mushroom-shaped  calcuh  the 
suprapubic  route  should  be  chosen.  A  collection  of  small  calculi 
in  one  lobe  of  the  prostate  should  be  removed  by  the  perineal 
route.  The  posterior  surface  of  the  prostate  is  exposed  by  a 
transverse  perineal  incision,  the  sheath  incised  over  the  collection, 


Fig.   1. — Shadow  of  large  single  prostatic  calculus. 

Fig.  2. — Shadows  of  small  irregular  scattered  prostatic 
calculi. 


Plate  42.    (P.  742. 


Tix]  CALCULUS  OF  PROSTATE  743 

and  the  calculi  removed  by  means  of  a  scoop  and  forceps  without 
opening  the  urethra.  When  the  prostate  is  slightly  enlarged  and 
calculi  are  present  in  both  lobes,  prostatectomy  should  be  performed 
by  the  perineal  route.  If  the  enlargement  of  the  gland  is  pro- 
nounced, suprapubic  prostatectomy  should  be  performed.  When 
the  calculus  occupies  a  pouch  communicating  with  the  urethra 
the  perineal  route  should  be  chosen  and  an  endeavour  made,  by 
scraping  with  a  sharp  spoon  and  cutting  Avith  scissors,  to  destroy 
the  pouch  and  prevent  recurrence, 

LITERATURE 

Bonneau,  Ann.  d.  Mai.  d.  Org.  Ghi.-  Urin.,  1908,  i.  1046. 

Burckhardt,   Krankh'>.iten  der  Prostata.     1902. 

Englisch,  Centralbl.  f.  d.  Krankh.  d.  Ham-  u.  Sex.-Org.,  1904,  p.  19. 

Falcone,  La  Clinica  Chirurgica,  1909,  p.  37. 

Fiirbringer,  Zcits.  /.  Urol.,  1911,  v.  169. 

Pasteau,  Ann.  d.  Mai.  d.  Org.   6en.-  Urin.,  1901,  p.  416. 


PART  VL—THE  SEMINAL  VESICLES  AND 
COWPER'S  GLANDS 

CHAPTER  LX 

ANOMALIES  AND  AFFECTIONS  OF  THE  SEMINAL 
VESICLES-COWPER^S  GLANDS 

Anatomy. — The  seminal  vesicles  are  two  hollow  organs  lying 
above  the  base  of  the  prostate  on  the  bladder  wall  between  the 
bladder  and  the  rectum.  They  are  2  in.  long  and  ^  in.  broad,  lie 
transversely  along  the  upper  border  of  the  prostate,  and  incline 
upwards,  especially  at  the  outer  end.  They  are  bound  to  the 
bladder  wall  by  a  layer  of  recto-vesical  fascia  continued  upwards 
from  the  back  of  the  prostate.  Above  and  internally  to  the  vesicles, 
and  closely  united  to  them,  are  the  ampullary  dilatations  of  the 
vasa  deferentia.  The  ureter  enters  the  wall  of  the  bladder  under 
cover  of  the  seminal  vesicle  on  each  side.  The  recto-vesical 
pouch  of  peritoneum  descends  so  as  to  cover  about  one-half  of 
the  breadth  of  each  vesicle.  The  relation  to  the  bladder  cavity 
is  shown  by  a  line  drawn  from  the  mid-point  of  the  trigone  out- 
wards and  backwards  so  as  to  round  the  ureteric  orifice  and  pass 
inwards  parallel  with  and  immediately  behind  the  base  of  the 
trigone  to  the  middle  line. 

Each  seminal  vesicle  consists  of  a  coiled  and  folded  tube  about 
6  in.  long,  which  has  numerous  diverticula.  At  the  inner  and 
lower  end  it  unites  by  a  narrow  duct  with  the  corresponding  vas 
deferens  at  an  acute  angle  to  form  the  common  ejaculatory  duct, 
which  opens  on  the  verumontanum.  The  function  of  the  seminal 
vesicle  is  to  store  spermatic  fluid,  to  which  it  adds  a  secretion 
supposed  to  stimulate  the  activity  of  the  spermatozoa. 

CONGENITAL   ANOMALIES   AND    ATROPHY 

Congenital  absence  is  rare,  usually  affects  one  side  only,  and 
is  combined  with  other  anomalies  of  the  genital  system  su£h  as 
malformation   of  the  urethra   and  prostate  and   absence   of  the 

744 


CHAP.  Lx]  SPERMATOCYSTITIS  745 

testicles.  The  condition  of  the  vesicles  is  not  so  closely  con- 
nected with  that  ot"  the  testich^  as  is  the  condition  of  the;  prostatic 
f^land.  The  testicle  and  epididymis  may  be  absent  or  rudimentary 
while  the  seminal  vesicles  are  present  and  well  developed,  or  the 
testicles  may  be  well  formed  and  the  seminal  vesicles  absent. 
Multiple  seminal  vesicles  have  been  described,  the  vesicle  being 
double  on  one  side.  Atrophy  has  been  noted  in  old  age  and 
after  inflammation  ;  it  is  independent  of  the  condition  of  the 
testicles.  The  ejaculatory  ducts  may  be  absent  or  fused,  or  may 
open  in  some  abnormal  position. 

SPERMATOCYSTITIS,   VESICULITIS 

Inflammation  of  the  seminal  vesicles  may  be  either  acute  or 
chronic,  and  is  invariably  secondary  to  inflammatory  disease  of 
the  urethra. 

Etiology. — Sexual  excesses  and  irregularities,  the  presence 
of  stricture  of  the  urethra,  or  chronic  urethritis,  prostatitis,  or 
cystitis,  are  predisposing  causes.  The  exciting  cause  is  most 
frequently  the  gonococcus,  and  the  vesiculitis  usually  complicates 
the  course  of  an  acute  attack  of  gonorrhoea ;  but  the  infection 
may  be  due  to  other  bacteria,  such  as  the  bacillus  coli,  staphylo- 
coccus, or  streptococcus. 

Pathology. — The  wall  of  the  vesicle  is  greatly  thickened,  and 
the  mucous  membrane  swollen  and  bright  red.  The  secretion  is 
retained  and  mixed  with  epithelial  debris,  spermatozoa,  and  pus. 
The  amount  of  pus  produced  is  moderate,  and  empyema  of  the 
seminal  vesicle  is  micommon. 

In  chronic  vesiculitis  fibrous  thickening  of  the  wall  takes  place 
and  perivesiculitis  is  commonly  present.  Atrophy  of  the  mucous 
membrane  occurs  in  some  cases,  and  may  affect  the  whole  vesicle. 
If  the  outlet  is  obstructed  the  muco-purulent  secretion  is  retained 
and  the  vesicle  becomes  distended.  This  may  be  combined  with 
great  thickening  of  the  walls  of  the  vesicles. 

Acute  Spermatocystitis 

Symptoms. — The  symptoms  of  acute  spermatocystitis  are 
usually  obscured  by  those  of  acute  inflammation  of  the  prostatic 
urethra.  During  an  attack  of  gonorrhoea  there  are  frequent  and 
urgent  micturition,  discomfort  at  the  neck  of  the  bladder,  scald- 
ing during  the  act,  and  there  may  be  terminal  hsematuria. 

Fever  is  sometimes  present,  but  the  temperature  is  rarely 
raised  more  than  one  or  two  degrees. 

The  symptoms  which  are  specially  produced  by  the  spermato- 
cystitis are  painful  erections  and  frequent  emissions.     The  seminal 


746  SEMINAL  VESICLES  [chap. 

fluid  is  stained  dark  bro\vii  with  changed  blood,  or  may  contain 
bright  blood  in  considerable  quantity  (hsemospermia). 

There  are  deep-seated  heavy  pain  in  the  perineum,  pain  and 
fullness  in  the  rectum,  and  intense  pain  on  defsecation.  Heavy 
aching  pain  is  felt  at  the  base  of  the  sacrum  and  in  the  region  of 
the  sacro-iliac  synchondrosis,  and  testicular  aching  is  common. 
A  sensation  of  fullness  in  the  bladder  and  rectum  is  usually 
present,  and  is  unrelieved  by  emptying  the  bladder  or  rectum. 

The  patient  is  examined  in  the  knee-elbow  position  on  a  couch. 
At  the  base  of  the  prostate,  passing  upwards  and  outwards  on 
one  or  both  sides,  a  sausage-shaped  swelling  is  felt.  It  is  doughy 
and  .very  tender. 

Course  and  complications. — The  inflammation  is  more  often 
subacute  than  acute,  and  the  symptoms  detailed  above  are  present 
in  a  slight  degree.  The  spermatocystitis  subsides  as  the  inflam- 
mation of  the  posterior  urethra  becomes  less  acute.  Pelvic  cellu- 
litis by  spread  to  the  surrounding  cellular  tissue  is  an  occasional 
complication,  and  more  severe  general  symptoms  then  develop. 
Prostatitis  and  epididymitis  are  frequent  complications.  Peri- 
tonitis and  even  pyaemia  have  occurred  in  rare  cases.  Rarely  the 
vesicle  becomes  distended  with  pus,  or  an  abscess  may  develop 
in  the  perivesicular  tissue.  The  vesiculitis  and  perivesiculitis  often 
become  chronic. 

Treatment.— In  the  acute  stage  active  local  treatment  of  the 
urethral  inflammation  should  be  suspended  and  the  treatment 
confined  to  diuretics  such  as  Contrexeville  water  and  sandalwood 
oil.  If  the  inflammation  is  severe,  and  if  there  is  a  rise  of  tempera- 
ture, the  patient  should  be  confined  to  bed.  The  rectum  should 
be  emptied  by  a  large  soap-and- water  enema.  Severe  pain  and 
irritation  are  allayed  by  hot  rectal  douches  or  by  the  injection 
of  a  small  quantity  (10  oz.)  of  hot  water  containing  antipyrin 
(20  gr.).  Suppositories  containing  morphia  (J  gr.)  and  extract  of 
belladonna  (J  gr.)  should  be  introduced  night  and  morning  in  an 
acute  case.  The  acute  stage  lasts  from  a  week  to  a  fortnight, 
unless  periprostatitis  is  present  as  a  complication,  when  the  dura- 
tion will  be  more  prolonged. 

Cheonic  Spermatocystitis 

Symptoms. — Chronic  spermatocystitis  is  usually  combined 
with  chronic  inflammation  of  the  prostatic  urethra. 

There  is  a  slight  increase  in  the  frequency  and  urgency  of  mic- 
turition, and  the  urine  contains  mucus  and  flakes.  If  posterior 
urethritis  is  absent  the  urine  is  clear.  There  may  be  slight  urgency 
of  micturition  and  scalding  during  the  act. 


Lx]  SPERMATOCYSTITIS :    DIAGNOSIS  747 

'I'ho  symptoms  arc  chiefly  sexual  and  neivous.  There  are 
fre(|ueiit  erections  and  emissions ;  the  scininal  liuid  is  mixed  with 
pus,  and  may  contain  brown  pigment  from  degenerated  bhjod. 
The  nervous  symptoms  are  pain,  depression,  lassitude. 

There  are  discomfort  in  the  urethra  and  aching  pain  in  the 
perineum,  rectum,  groins,  thighs,  sacral  base,  sacro-iliac  syn- 
chondrosis, and  frequently  pains  are  felt  in  more  distant  parts 
such  as  the  shoulders  and  neck. 

In  old-standing  cases  the  patients  become  neurasthenic,  dys- 
peptic, and  sometimes  almost  melancholic. 

Spermatorrhoea  may  be  present,  but  this  condition  may  occur 
without  vesiculitis.  It  consists  in  the  discharge  of  seminal  fluid 
containing  spermatozoa  and  other  elements  Avithout  erection  or 
desire.  The  fluid  is  mixed  with  pus  cells,  and  sometimes  with 
red  blood-corpuscles. 

On  rectal  examination  the  vesicles  are  found  to  be  thickened 
and  tough,  and  their  outline  can  be  defined. 

An  atrophic  type  is  also  described. 

Diagnosis. — The  local  symptoms  may  be  slight  and  neuras- 
thenia well  developed,  so  that  the  vesiculitis  is  overlooked.  The 
rectum  should  therefore  be  examined  in  all  doubtful  cases. 

A  dilated  normal  seminal  vesicle  can  frequently  be  detected 
as  a  soft,  sausage-shaped  cushion.  In  chronic  vesiculitis  the  wall 
is  uniformly  thickened  and  tough,  and  tenderness  is  in  many 
cases  present. 

In  tuberculous  disease  the  vesicle  is  hard  and  nodular,  and 
only  a  part  of  the  vesicle  may  be  aflected.  The  vesicle  frequently 
feels  like  a  string  of  small  beads,  or  there  may  be  one  or  two 
separate  nodules. 

Chronic  urethritis  is  often  present  and  obscures  the  symp- 
toms of  chronic  vesiculitis.  The  diagnosis  is  made  by  rectal 
examination,  and  by  microscopical  examination  of  the  fluid  ob- 
tained from  the  vesicles  by  massage. 

If  chronic  urethritis  is  present  the  urethra  is  first  washed  by 
Janet's  method.  The  patient  is  then  placed  in  the  knee-elbow 
position  wdth  a  receptacle  imder  the  penis  and  the  vesicles  are 
massaged.  The  fluid  may  drop  from  the  urethra  into  the  receptacle, 
or  may  be  expressed  from  the  urethra  by  stripping  it  forwards. 
The  presence  of  pus  and  blood  in  the  expressed  fluid  indicates 
vesiculitis. 

Treatment. — It  is  important  to  empty  the  vesicles  of  in- 
flammatory products  which  accumulate  in  the  branches  and 
pockets  of  these  hollow  organs.  This  is  done  by  massage.  The 
patient  is  placed  in  the  knee-elbow  position,  the  forefinger  of  the 


748  SEMINAL  VESICLES  [chap. 

gloved  right  liand  is  introduced  into  the  rectum  and  feels  for  the 
vesicle  above  the  corresponding  lobe  of  the  prostate.  Unless  the 
surgeon's  finger  is  unusually  short  or  the  perineum  of  the  patient 
deep,  the  forefinger  reaches  to  the  tip  of  the  vesicle  without 
difficulty  {see  p.  674).  The  finger  strips  the  vesicle  from  without 
inwards  and  downwards  with  a  firm,  even  pressure.  This  is  done 
several  times,  and  the  second  vesicle  then  treated  similarly.  The 
contents  of  the  vesicle  appear  at  the  external  meatus,  or  they 
may  be  expressed  from  the  urethra,  and  are  examined  micro- 
scopically. Thomas  recommends  that  the  massage  should  be 
carried  out  with  the  patient  standing  with  the  legs  widely  apart. 
When  chronic  urethritis  is  present  the  massage  is  followed  by 
irrigation  of  the  urethra  by  Janet's  method.  A  metal  shield  or 
thimble  to  assist  and  extend  the  reach  of  the  forefinger  has  been 
suggested,  but  is  unnecessary.  The  treatment  is  repeated  once 
or  twice  a  week,  and  extends  over  several  weeks.  Great  care 
should  be  taken  to  select  the  proper  cases.  Acute  and  subacute 
cases  are  unsuitable,  and  an  exacerbation  of  subacute  or  acute 
symptoms  should  be  the  signal  for  abandoning  the  treatment. 
Tuberculous  disease  of  the  prostate  and  seminal  vesicles  must 
be  excluded  with  absolute  certainty  before  undertaking  vesicular 
massage  ;   much  harm  is  done  by  applying  it  to  tuberculous  cases. 

Suppositories  containing  ichthyol,  3  gr.,  or  potassium  iodide, 
5  gr.,  should  be  introduced  night  and  morning.  Rectal  irrigations 
of  hot  water  are  occasionally  of  benefit  where  pelvic  cellulitis  is 
present  or  where  pain  is  a  marked  feature ;  they  are  given  each 
night.  Occasionally  cold  douches  are  found  more  effective.  Iodide 
of  potash,  10  gr.,  is  the  best  drug  for  internal  administration.  The 
treatment  of  chronic  urethritis  (p.  613)  should  run  concurrently 
with  that  of  vesiculitis. 

Vaccine  treatment  should  be  resorted  to  in  chronic  cases.  A 
vaccine  is  prepared  from  cultures  obtained  from  the  fluid  expressed 
from  the  vesicles. 

Operative  treatment. — This  may  be  called  for  in  chronic 
vesiculitis  which  persists  in  spite  of  other  treatment,  but  the 
cases  in  which  it  becomes  necessary  are  rare.  Fuller  has  strongly 
advocated  vesiculotomy  in  intractable  cases. 

The  vesicles  are  exposed  by  the  curved  prerectal  incision  of 
Zuckerkandl  used  for  perineal  prostatectomy.  The  patient  is 
placed  in  the  lithotomy  position  with  a  cushion  under  the  sacrum, 
and  the  posterior  surface  of  the  prostate  exposed.  Further  separ- 
ation of  the  rectum  from  the  base  of  the  prostate  with  the  fore- 
fingers exposes  the  vesicles.  The  rectum  is  displaced  backwards 
with  a  suitable  retractor  and  the  cavity  illuminated  with  a  powerful 


Lx]  SPERMATOGYSTITIS :   TREATMENT  749 

head-light.  The  fascia  over  the  seminal  vesicle  is  incised  and  the 
organ  separated  by  blunt  dissection,  care  being  necessary  at  the 
outer  extremity,  which  is  in  close  relation  to  the  trunks  of  the 
prostato-vesical  venous  plexus.  The  vesicle  is  either  laid  open 
and  drained  or  it  is  dissected  up  from  without  inwards  and 
removed. 

In  Fuller's  operation  the  patient  is  placed  in  a  kneeling  posi- 
tion with  the  chest  on  the  table,  and  supported  by  assistants.  An 
incision  is  made  alongside  the  anus  from  the  border  of  the  coccyx 
downwards  and  inwards  just  within  the  inner  border  of  the  ischium 
to  I  in.  in  front  of  the  anus.  A  similar  incision  is  made  on  the 
other  side,  and  the  anterior  extremities  of  the  two  incisions  are 
joined  across  the  perineum.  The  rectum  is  separated  from  the 
urethra  and  prostate.  The  tip  of  the  right  forefinger  searches 
for  the  apex  of  the  seminal  vesicle,  and  along  it  a  grooved  director 
is  slipped.  A  knife  is  passed  along  this,  and  the  point  enters  the 
apex  of  the  vesicle,  the  vesicle  being  then  laid  open ;  and  this  is 
repeated  on  the  second  side.  The  cavity  is  curetted  and  packed. 
Fuller  has  performed  this  operation  126  times  without  a  death. 

The  seminal  vesicle  may  also  be  exposed  by  an  incision  above 
and  parallel  with  Poupart's  hgament ;  the  steps  are  the  same  as 
in  exposing  the  pelvic  portion  of  the  ureter.  The  exposure  is 
not  good,  and  the  operation  may  be  difficult  in  a  stout  subject. 
The  seminal  vesicles  can  be  exposed  at  the  bottom  of  the  recto- 
vesical pouch  after  opening  the  peritoneal  cavity  by  a  vertical 
median  suprapubic  incision.  The  patient  is  placed  in  the  Tren- 
delenburg position  and  the  intestines  are  packed  off.  A  transverse 
incision  through  the  peritoneum  at  the  lower  part  of  the  recto- 
vesical pouch  exposes  the  vesicles. 

LITERATURE 

Barnett,  N.  Y.  Med.   Joum.,  May  21,  1910. 

Eastman,  N.  Y.  Med.   Journ.,  Oct.  27,  1900. 

Fuller,  Med.  Eec,  1909,  p.  717:    N.  Y.  Med.  Journ.,  May  30,  1908. 

Gruber,  Munch,  med.  Woch.,  1911,  Nr.  19. 

Lloyd,  Jordan,  Lancet,  1891,  ii.  975. 

Swinburne,  Journ.  of  Gutan.  and  Gen.-  Urin.  Dis.,  March,  1898. 

Thomas,    Internat.  Med.  Mag.,  Jan.,  1901. 

TUBERCULOSIS  OF   THE   SEMINAL  VESICLE 

The  seminal  vesicle  is  seldom  affected  alone.  Most  frequently 
either  the  epididymis  or  the  prostate,  or  both,  are  also  tuberculous. 
Of  94  cases  of  genital  tuberculosis  under  my  care  the  seminal 
vesicle  was  affected  in  37  (39-3  per  cent.),  the  infection  being 
unilateral  in  26  and  bilateral  in  IL 

In  only  3  cases  was  the  seminal  vesicle  the  only  genital  organ 


750  SEMINAL  VESICLES  [chap. 

affected,  and  in  but  1  was  it  the  solitary  focus  of  tubercle,  the 
bladder  being  affected  in  the  other  2. 

The  organ  most  frequently  affected  alone  with  the  senainal 
vesicle  was  the  epididymis  (14  cases)  ;  the  prostate  was  affected 
alone  with  the  seminal  vesicle  in  5  cases,  and  both  the  prostate 
and  epididymis  with  it  in  16  cases. 

The  average  age  was  30  years,  the  youngest  being  18  years. 

The  tuberculous  process  is  very  rarely  in  the  form  of  miliary 
tubercle.  In  most  instances  caseous  nodules  are  formed.  The 
inner  end  of  the  vesicle  is  first  affected,  and  later  the  whole 
organ  becomes  a  nodular  mass.  The  disease  is  chronic,  and  the 
wall  may  undergo  fibrous  induration,  the  vesicle  shrinking  to  form 
a  hard,  rigid  mass.  Rupture  of  the  tuberculous  collection  may 
take  place  after  adhesions  into  the  rectum  or  through  the  bladder 
wall  into  this  viscus.  Less  frequently  the  abscess  tracks  down- 
wards into  the  perineum,  or  unites  with  a  prostatic  collection 
and  ruptures  into  the  urethra. 

Symptoms. — Usually  the  symptoms  are  slight,  and  they  may 
be  entirely  wanting.  The  affection  of  the  vesicle  is  generally  dis- 
covered on  examining  a  case  in  which  tuberculous  epididymitis  or 
prostatitis  is  present,  or  vesical  tuberculosis. 

In  rare  cases  the  onset  and  course  are  acute,  and  acute  gonor- 
rhoeal  spermatocystitis  is  simulated. 

The  symptoms  which  point  to  tuberculous  cystitis  are  sexual 
irritation,  frequent  erections,  and  painful  and  bloody  emissions. 
There  may  be  pain  at  the  root  of  the  penis  or  in  the  groin. 

Frequent  micturition  is  often  present,  and  is  due  to  involve- 
ment of  the  prostate  and  bladder  base.  Spread  to  the  bladder 
may  be  slow,  or  a  tuberculous  collection  may  rupture  into  the 
bladder.  In  the  latter  case  there  is  a  history  of  haematuria,  which 
may  be  severe,  and  of  frequent  micturition. 

Rectal  examination  in  the  knee-elbow  position  shows  a  nodular 
vesicle.  There  is  a  single  nodule  at  the  inner  extremity  of  the 
vesicle,  or  a  series  of  nodules  closely  set,  and  when  the  whole 
organ  is  affected  a  hard,  craggy,  elongated  body  is  felt  lying  just 
above  the  prostate  and  extending  outwards  and  upwards.  The 
vesicle  is  tender  on  palpation.     The  prostate  may  contain  nodules. 

On  cystoscopy  the  bladder  is  normal,  or  if  it  has  been  infected 
from  the  vesicle  it  shows  tuberculous  lesions  immediately  behind 
the  base  of  the  trigone. 

Course  and  prognosis. — In  the  majority  of  cases  the  course 
is  very  chronic.  The  vesicle  may  shrink  and  remain  as  a  small, 
hard  band  for  years  without  any  change.  After  some  years' 
quiescence  renewed  activity  may  lead  to  spread  of  the  tuberculous 


i\]     TUBERCULOSIS  OF  SEMINAL  VESICLE      751 

process.  The  chief  danger  is  that  it  may  spread  to  the  bladder, 
and  the  genital  become  urinary  tuberculosis.  This  had  occurred 
in  14  out  of  37  cases  under  my  care.  Less  frequently  the  kidney 
is  affected  alone  with  the  seminal  vesicle  and  other  genital  organs 
(2  cases). 

Treatment. — The  general  condition  of  the  patient  should  be 
improved  by  a  nourishing  diet  with  plenty  of  milk  and  cream, 
and  cod-liver  oil  and  malt,  and  he  should  live  an  outdoor  life  in 
a  warm,  dry  climate. 

Tuberculin  treatment  should  be  commenced  as  early  as 
possible  and  continued  for  two  or  more  years  {see  p.  689).  The 
results  of  this  treatment  are  good  ;  the  tuberculous  vesicle  shrinks 
and  becomes  quiescent. 

Operation. — Excision  of  the  seminal  vesicles  has  a  small 
mortality  (2  per  cent.).  The  cases  in  which  the  seminal  vesicles 
alone  are  affected  being  rare,  it  will  usually  be  necessary  to  remove 
the  prostate  and  epididymis  at  the  same  time. 

The  perineal  route  should  be  chosen  {see  p.  748).  A  sinus 
remains  in  a  considerable  number  of  cases,  due  to  tuberculous 
infection  of  the  wound.   -Urinary  fistulse  have  also  been  recorded. 

The  cases  suitable  for  this  operation  are  not  very  numerous. 
It  should  be  followed  by  a  prolonged  course  of  tuberculin. 

Where  the  epididymis  is  tuberculous  on  one  or  both  sides, 
epididymectomy  or  castration  may  be  performed  in  addition  to 
this  operation.  It  has  usually  been  found  that  removal  of  the 
tuberculous  epididymis  or  testicle  has  a  beneficial  effect  on  the 
seminal  vesicle,  and  operation  upon  the  vesicle  may  not  be  required. 
Heroic  operations  for  the  removal  of  the  testicles,  vasa  deferentia, 
seminal  vesicles,  and  prostate  have  not  given  satisfactory  results 
and  have  been  abandoned  by  most  surgeons. 

LITERATURE 

Cholzoff,  Folia  Urol.,  1908,  p.  555. 

Guelliot,  PressG  Med.,  1898,  p.  193. 

Legueu,  BuU.  et  Mem.  de  la  Sac.  de  Cliir.,  Paris,  1905,  p.  136. 

Walker,  Thomson,  PracU,  May,  1908. 

VESICULAR  NEW  GROWTHS  AND  CONCRETIONS 

The  seminal  vesicle  is  occasionally  invaded  by  carcinoma  of 
the  prostate.  More  frequently  the  ejaculatory  ducts  are  obUter- 
ated,  and  the  vesicles  become  distended  and  the  walls  thickened. 
Only  two  or  three  cases  of  primary  carcinoma  of  the  seminal  vesicles 
are  on  record.  I  have  diagnosed  the  condition  clinically  in  two 
cases  in  which  a  growth  that  pursued  a  malignant  course  com- 
menced in  the  region  of  the  seminal  vesicle. 


752  SEMINAL  VESICLES  [chap,  lx 

Two  cases  of  sarcoma  have  been  described. 

Single  or  multiple  concretions  are  sometimes  found  in  the 
seminal  vesicles  in  middle  or  old  age.  They  are  fawn-coloured, 
yellow,  brown,  or  black.  At  first  they  are  soft,  and  consist  of 
spermatozoa,  mucus,  and  epithelium ;  on  this  phosphates  and 
carbonate  of  lime  are  deposited,  and  a  hard  concretion  is  formed 
which  may  reach  the  size  of  a  cherry.  The  ejaculatory  ducts  are 
frequently  obstructed.  There  are  sexual  irritation,  painful  ejacu- 
lation, pain  in  defeecation,  and  occasionally  aspermia.  The  con- 
cretion is  felt  as  a  round  nodule  in  the  seminal  vesicle. 

Soft  concretions  may  be  crushed  with  the  finger  and  small 
calculi  expelled  by  massage.  It  has  not  been  found  necessary 
to  remove  the  concretions  by  operation. 

COWPEE'S  GLANDS 

Cowper's  glands  are  two  small  tubular  glands  lying  on  each 
side  of  the  membranous  urethra  between  the  bundles  of  the  com- 
pressor urethree.  The  ducts  pass  for  an  inch  to  open  on  the  floor 
of  the  bulbous  urethra  ;  occasionally  they  imite  to  form  a  single 
duct  which  opens  in  the  middle  line.  With  the  urethroscope  and 
air  distension  of  the  urethra  the  ridge  formed  by  the  ducts  can 
usually  be  seen  on  the  floor  of  the  bulbous  urethra.  Cystic  dilata- 
tion of  the  duct  has  already  been  described  (p.  659).  With  the 
forefinger  in  the  rectum  at  the  side  of  the  membranous  urethra 
and  the  thumb  pressing  up  from  the  perineum,  the  gland  of  one 
side  is  between  the  finger  and  thumb,  but  it  cannot  be  felt  in  the 
normal  state.     {See  p.  555.) 

Acute  inflammation  (badly  named  Cowperitis)  occurs  as  a  com- 
plication of  acute  urethritis,  and  is  usually  due  to  the  gonococcus. 
An  abscess  may  form,  and  points  alongside  the  bulb  in  the  perineum, 
or  it  may  open  into  the  bulbous  urethra  or  rectum. 

Chronic  inflammation  causes  discomfort  and  pain  on  sitting. 
The  gland  can  be  felt  as  a  hard,  tender,  pea-sized  body. 

If  troublesome  the  gland  should  be  removed,  either  by  a  trans- 
verse prerectal  incision,  or  by  an  oblique  antero-posterior  incision 
alongside  the  bulb. 

Carcinoma  of  Cowper's  gland  has  been  described,  but  is  very 
rare. 


PART  VIL-THE  TESTICLE 


CHAPTER  LXI 

ANATOMY  AND  MALFORMATIONS-INJURIES 
AND   WOUNDS— TORSION 

Surgical  anatomy. — The  testicles  are  contained  in  the  scrotum, 
separated  by  a  median  septum.  The  left  hangs  lower  than  the 
right.  The  organs  are  suspended  in  a  vertical  position  by  the 
spermatic  cords,  with  the  body  turned  a  little  outwards  and 
the  upper  end  tilted  slightly  forwards. 

The  gland  consists  of  the  testicle  and  the  epididymis. 

The  testicle  is  covered  by  the  visceral  layer  of  the  tunica  vagi- 
nalis, which  is  adherent  to  it.  This  serous  membrane  covers  the 
globus  major  and  the  outer  part  of  the  body  of  the  epididymis, 
and  dips  in  between  the  epididymis  and  the  testicle  on  the  outer 
side  to  form  the  digital  fossa.  The  surfaces  are  lubricated  by  a 
small  amount  of  serous  fluid. 

The  testicle  is  covered  by  a  dense  fibrous  capsule,  the  tunica 
alhuginea.  At  the  back  of  the  testicle  this  forms  a  mass,  the 
mediastinum  testis,  from  which  septa  radiate  through  the  gland 
to  the  inner  surface  of  the  tunica  albuginea.  In  this  connective- 
tissue  framework  are  small  collections  of  polyhedral  cells  like 
the  cortical  cells  of  the  suprarenal  capsules,  and  containing  yellow 
granules.  These  surround  capillary  blood-vessels  and  are  named 
the  "  interstitial  cells "  of  the  testicle.  Between  150  and  200 
compartments  are  formed  by  the  fibrous  septa,  and  contain  the 
convoluted  tiihidi  semirdferi,  300  to  400  in  number.  By  the  union 
of  these  tubules  larger  tubes  {tuhuli  recti)  are  formed,  and  these 
form  a  plexus  (rete  testis)  in  the  mediastinum.  From  the  larger 
tubes  vasa  efferentia,  12  to  20  in  number,  emerge  and  enter  the 
head  of  the  epididymis. 

The  epididymis  consists  of  a  head  (globus  major),  a  body,  and 

a  tail  (globus  minor).     It  is  attached  to  the  back  of  the  testis 

by  the  vasa  efferentia,  which  enter  the  globus  major,  the  body 

being  attached  only  by  areolar  tissue.     After  entering  the  globus 

2  w  753 


754  THE   TESTICLE  [chap. 

major  each  vas  efferens  becomes  coiled  into  a  cone  (conus  vascu- 
losus),  and  they  all  terminate  in  a  single  collecting  tube  (tube  of 
the  epididymis),  which  is  coiled  and  twisted  (15  to  20  feet  long) 
to  form  the  epididymis,  and  ends  in  the  vas  deferens. 

Certain  vestigial  remains  are  found  in  relation  to  the  testis 
and  epididymis.  The  vas  aberrans  is  a  narrow  coiled  diverticulum 
2-12  in.  long,  arising  from  the  lower  end  of  the  canal  of  the  epi- 
didymis. It  originates  in  the  Wolffian  duct.  The  organ  of  Giraldes, 
or  'paradidymis,  is  part  of  the  Wolffian  body,  and  consists  of  several 
small,  irregular  masses  of  convoluted  tubules  situated  on  the 
front  of  the  cord  immediately  above  the  head  of  the  epididymis. 

The  hydatids  of  Morgagni  are  one  or  more  small  pedunculated 
bodies  attached  to  the  front  of  the  globus  major  and  testicle. 
They  consist  of  blood-vessels  and  connective  tissue,  and  may 
contain  a  canal  lined  by  cihated  epithehum.  They  are  remains 
of  part  of  Miiller's  duct. 

The  spermatic  cord  contains  the  vas  deferens,  which  lies  behind 
the  other  structures  and  has  the  deferential  vessels  in  close  relation 
to  it,  the  spermatic  artery  and  plexus  of  veins  (pampiniform  plexus), 
lymphatics,  sympathetic  nerves,  the  remains  of  the  connection 
between  the  tunica  vaginahs  and  peritoneum  (processus  vaginalis), 
areolar  tissue,  fat,  and  smooth  muscle  fibres  (internal  cremaster). 

The  veins  are  arranged  in  two  groups.  The  spermatic  veins, 
surrounding  the  spermatic  artery,  arise  from  the  upper  part  of  the 
testicle  and  run  in  front  of  the  deferential  veins,  which  form  the 
second  group  and  surround  the  vas  deferens. 

According  to  Jamieson  and  Dobson,i  the  collecting  lymphatic 
vessels,  four  to  eight  in  number,  ascend  with  the  veins  in  the  cord 
and  in  the  subperitoneal  tissues  over  the  psoas  as  far  as  the  point 
where  the  spermatic  vessels  cross  the  ureter  ;  here  they  part  from 
the  blood-vessels  and  extend  fan-wise  into  the  lumbar  glands. 
The  lymphatic  glands  are  those  glands  of  the  lumbar  group  in 
front  of  and  by  the  sides  of  the  aorta  and  vena  cava  below  the 
level  of  the  renal  veins,  and  are  members  of  the  external  group. 
The  glands  of  each  testicle  communicate  with  each  other. 

Descent  of  the  testicle. — The  testicle  is  developed  in  close 
relation  to  the  kidney,  and  is  invested  by  a  layer  of  peritoneum, 
the  mesorchium.  Strands  of  non-striped  muscle  fibres  (guberna- 
culum  testis)  connect  the  testicle  with  the  pillars  of  the  external 
abdominal  ring,  the  front  of  the  pubes,  and  with  the  skin  of  the 
scrotum,  Scarpa's  triangle,  and  perineum. 

The  testicle,  before  it  commences  to  descend,  is  already  low 

1  Lancet,  1910,  i.  493. 


Lxi]  ATROPHY  OF  TESTICLE  755 

down  in  the  abdomen,  and  the  distance  from  the  external  abdo- 
minal ring  is  very  small. 

By  a  gradual  process  of  development,  especially  the  develop- 
ment of  the  pelvis  and  the  growth  of  the  lumbar  spine,  the  testicle 
comes  to  lie  at  the  brim  of  the  pelvis  and  reaches  the  internal 
abdominal  ring  at  the  sixth  month.  Preceded  by  a  process  of 
peritoneum  (processus  vaginalis),  and  accompanied  by  some  fat 
and  extraperitoneal  tissue,  the  testicle  now  passes  obliquely  through 
the  abdominal  wall,  reaching  the  external  abdominal  ring  during 
the  seventh  or  eighth  month.  At  the  end  of  the  eighth  or  during 
the  ninth  month  it  has  arrived  at  the  bottom  of  the  scrotum. 

ATROPHY  OF   THE  TESTICLE 

"  Atrophy  "  of  the  testicle  may  be  arrest  of  development  or 
atrophy  after  full  development.  Arrest  of  development  is  seen 
in  the  imperfectly  descended  and  ectopic  testicle,  or  the  testicle 
may  descend  into  the  scrotum  but  remain  infantile  in  its  propor- 
tions. A  varying  degree  of  atrophy  of  the  testicle  is  present  in 
almost  all  cases  of  varicocele.  Should  both  testicles  fail  to  develop, 
the  secondary  sexual  characteristics  of  the  male  do  not  appear. 
The  voice  remains  a  high-pitched  treble,  the  face  is  smooth  and 
hairless,  the  figure  plump  and  rounded.  Mental  deficiency  becomes 
evident  in  some  cases. 

Atrophy  after  full  development  may  result  from  many  con- 
ditions. In  the  majority,  orchitis  precedes  the  atrophy,  which 
is  a  process  of  sclerosis.  Epididymo-orchitis  due  to  gonorrhoea, 
mumps,  typhoid  fever,  bacillus  coU  or  other  bacterial  infection, 
is  the  most  common.  Traumatic  orchitis  is  a  not  infrequent 
cause,  atrophy  following  a  crush  of  or  blow  upon  the  testicle. 
Syphilitic  orchitis  is  less  common. 

Orchitis  is  said  to  complicate  mumps  in  60  per  cent,  of  cases, 
and  atrophy  very  frequently  results.  Heller  foimd  that  of  10 
cases,  in  adults,  of  mumps  complicated  with  orchitis,  atrophy  fol- 
lowed in  5,  Torsion  of  the  cord  produces  atrophy  of  the  testicle. 
Atrophy  has  been  known  to  follow  injuries  to  the  brain  and  spinal 
cord  in  some  manner  unexplained. 

Senile  atrophy  occurs  in  extreme  old  age,  but  may  commence 
as  early  as  the  fiftieth  year  in  exceptional  cases. 

In  cases  in  which  the  testicle  has  not  developed,  or  the  atrophy 
is  due  to  cutting  off  of  the  blood  supply,  the  testicle  is  soft  and 
inelastic.  On  section  there  is  widespread  fatty  degeneration,  but 
no  sclerosis.  When  the  testicle  has  atrophied  as  the  result  of 
inflammatory  changes  due  to  syphilis  or  traumatism  it  is  tough, 
or  even  hard,  and  the  gland  tissue  is  sclerosed,  the  tubules  being 


756  THE  TESTICLE  [chap. 

compressed  by  the  increased  interstitial  fibrous  tissue.  Occasion- 
ally the  atrophied  testicle  following  inflammatory  disease  is  soft 
and  flabby,  and  here  the  atrophy  probably  results  from  inter- 
ference with  the  blood  supply  rather  than  from  sclerosis  of  the 
gland  tissue. 

In  conjunction  with  testicular  atrophy  the  mammae  in  rare  cases 
become  enlarged,  either  from  an  increased  deposit  of  fat  or  from 
a  true  h5rpertrophy  of  the  glandular  tissue.  When  both  testicles 
are  atrophic,  sterility  ensues.  Not  infrequently  sterility  results 
from  atrophy  of  one  testicle  and  thickening  of  the  epididymis, 
with  blocking  of  the  tube  on  the  second  side,  the  result  of  an  attack 
of  epididymitis. 

Treatment  consists  in  the  treatment  of  the  conditions  causing 
atrophy.  There  is  no  means  of  arresting  atrophy  when  it  has 
once  commenced. 

ANORCHISM,  MONORCHISM 

Congenital  absence  of  one  or  both  testicles  is  an  uncommon 
condition.  It  is  not  possible  to  obtain  reliable  proof  of  this  con- 
dition during  life,  as  the  testicle  may  be  undescended,  or  imper- 
fectly descended,  and  very  small.  The  testicle  may  be  absent 
and  the  epididymis  developed,  but  much  more  frequently  the 
testis,  epididymis,  and  part  of  the  vas  deferens  are  wanting.  The 
portion  of  the  vas  deferens  nearest  the  seminal  vesicle  is  usually 
present,  but  occasionally  this  also  is  absent  and  the  seminal  vesicle 
is  rudimentary. 

In  bilateral  anorchism  the  external  genitals  are  rudimentary, 
and  the  secondary  sexual  characteristics  of  the  male  do  not  develop. 
Other  malformations  may  be  associated  with  these  conditions. 
The  kidney  and  ureter  may  be  absent,  rudimentary,  or  malformed 
on  the  side  on  which  the  testicle  is  absent,  and  there  may  also  be 
imperforate  anus,  urethro-rectal  and  vesico-rectal  fistulse. 

INJURIES   OF   THE   TESTICLE 

Severe  injuries  to  the  testicles  are  uncommon.  Kicks,  falls 
astride,  the  blow  of  a  cricket-ball,  the  impact  of  a  wheel  in  carriage 
accidents,  are  the  types  of  violence  by  which  the  injury  is  produced. 

Extensive  ecchymosis  of  the  scrotum  rapidly  follows. 

The  testicle  has  been  dislocated  on  to  the  pubes,  the  perineum, 
or  even  the  thigh,  but  the  more  frequent  form  of  injury  consists 
in  haemorrhage  into  the  testicle  or  epididymis.  The  blood  may 
accumulate  under  the  tunica  albuginea,  or  form  small  collections 
in  the  substance  of  the  testicle.  Rupture  of  the  tunica  albuginea 
follows  more  severe  crushes.     Epididymitis  and  orchitis  ensue. 


Lxi]  INJURIES   OF  TESTICLE  757 

Symptoms. — Sevei'e  shock  results  from  a  blow  on  the  testicle, 
and  Kocher  cjuotes  two  deaths  from  shock  caused  by  such  an 
injury.  In  less  severe  cases  there  is  a  heavy,  depressing  pain, 
with  nausea  and  vomiting.  The  testicle  becomes  tense  and  greatly 
increased  in  size,  and  the  epididymis  rapidly  enlarges.  The  scrotum 
is  swollen  with  effused  blood,  and  widespread  ecchymosis  rapidly 
appears.  The  scrotum  and  testicle  are  intensely  tender.  Under 
treatment  the  pain  and  swelling  subside,  but  epididymitis  fre- 
quently follows  and  the  haematocele  persists.  At  a  later  date 
atrophy  of  the  testicle  frequently  occurs.  Suppuration  occasion- 
ally follows  injury. 

Repeated  injuries  to  a  partly  descended  testicle  result  in  fibrosis 
of  an  already  imperfectly  developed  organ. 

The  relation  of  hydrocele,  tuberculosis  of  the  epididymis,  and 
new  growths  to  injury  is  not  clearly  defined,  although  it  is  common 
to  obtain  a  history  of  a  blow  on  the  testicle  in  these  diseases. 
There  is  danger  of  attributing  to  injury  diseases  of  the  testicle 
which  were  present  before  the  injury  was  inflicted,  and  to  which 
the  injury  merely  draws  attention. 

Treaiment. — Dislocation  of  the  testicle  is  treated  by  manipu- 
lation under  an  anaesthetic,  and,  failing  that,  the  displaced  organ 
is  exposed  by  operation  and  replaced  in  the  scrotum.  After 
severe  injury  to  the  testicle  the  patient  should  be  confined  to  bed 
and  the  scrotum  supported  on  a  pillow  or  slung  upon  a  broad 
band  of  strapping  which  passes  between  the  thighs,  and  cooling 
lotions  or  an  ice-bag  applied.  Where  the  tension  and  pain  due 
to  extravasation  of  blood  within  the  tunica  albuginea  are  very 
great,  punctures  with  a  tenotomy  knife  may  give  relief.  When 
epididymitis  and  orchitis  develop,  hot  fomentations  should  be 
applied.     Very  rarely  abscess  results  and  necessitates  incision. 

WOUNDS   OF  THE  TESTICLE 

These  most  frequently  occur  from  the  puncture  of  a  trocar 
in  tapping  a  hydrocele.  The  puncture  in  the  tunica  albuginea 
may  be  small  and  rapidly  close,  but  not  infrequently  a  haemato- 
cele is  the  result,  and  this  may  recur  after  tapping. 

Incised  and  stab  wounds  occur  apart  from  surgical  procedures, 
and  the  testicle  may  be  prolapsed  through  a  wound  in  the  scrotum 
and  lacerated  or  incised. 

Treatment. — Haematocele  following  puncture  of  the  testicle 
is  treated  by  rest  in  bed,  support  of  the  testicle,  and  an  ice-bag. 
The  collection  should  be  withdrawn  by  tapping  after  some  days. 
An  operation  may  be  necessary  to  remove  masses  of  laminated 
clot. 


758  THE  TESTICLE  [chap. 

An  exposed  incised  testicle  should  be  treated  by  suture  of 
the  tunica  albuginea  and  replacement  of  the  organ. 

TORSION  OR  VOLVULUS  OF   THE  TESTICLE 

Torsion  of  the  testicle  is  comparatively  rare.  Corner  collected 
100  cases  from  the  literature  and  added  9  personal  cases. 
The  condition  most  often  arises  before  or  shortly  after  puberty. 
About  70  per  cent,  of  cases  occur  before  the  age  of  20.  A  case 
has  been  described  in  a  child  four  hours  after  birth  (Taylor). 
Torsion  occurring  in  adults  is  uncommon,  but  a  few  cases:  have 
been  described  after  the  age  of  40.  The  right  testicle  is  the  more 
frequently  affected  (60  per  cent.),  and  the  condition  is  always 
unilateral. 

Etiology. — In  the  majority  of  cases  the  testicle  is  imper- 
fectly descended,  but  a  few  cases  are  recorded  (Edington)  in  which 
a  fully  descended  organ  was  the  seat  of  volvulus. 

Abnormality  of  the  cord  exists  previously  to  the  torsion. 
According  to  Lauenstein  the  cord  is  broad,  and  the  testicle  lies 
with  its  long  axis  horizontal  (reversion  of  the  testis).  From  the 
lower  end  of  the  testicle  the  vas  deferens  arises,  while  the  principal 
group  of  veins  passes  to  the  globus  major  at  the  upper  end.  Rota- 
tion of  the  horizontally  placed  testicle  leads  to  twisting  of  these 
structures.  Moreover,  the  testicle  appears  to  be  unduly  mobile 
within  the  tunica  vaginalis.  This  may  be  due  to  the  gland  hanging 
loose  in  the  tunica  vaginalis  by  a  mesorchium  formed  of  two  layers 
of  the  serous  membrane  attached  the  whole  length  of  the  epididy- 
mis or  only  at  the  upper  part.  Adhesion  to  the  bottom  of  the 
scrotum  is  said  to  be  deficient  in  these  cases. 

The  relation  of  the  tunica  vaginalis  to  the  testicle  and  epi- 
didymis may  be  unaltered,  but  in  some  cases  the  epididymis  has 
been  found  completely  within  the  cavity  of  the  tunica  vaginalis. 

The  exciting  cause  is  sometimes  traced  to  muscular  exertion 
or  injury.     Crossing  the  legs  has  brought  on  an  attack. 

Pathology. — Examined  from  the  front  the  twist  is  from  left 
to  right  on  the  right  side,  and  from  right  to  left  on  the  left  side. 
The  pedicle  is  twisted  from  half  a  turn  to  four  or  five  turns.  The 
twist  affects  the  cord ;  or,  where  the  epididymis  and  testicle  are 
separated  by  a  considerable  interval,  the  mesorchium  formed  by 
the  tunica  vaginalis  between  the  structures  may  be  twisted.  The 
testicle  and  epididymis  are  engorged  with  blood  from  the  venous 
obstruction.  The  organ  is  a  deep  purple  colour,  and  patches  of 
extravasated  blood  are  found  in  the  substance  of  the  testis. 
Infection  of  the  strangulated  organ  occurs  early,  especially  if 
a  hernia  is  present,  and  gangrene  supervenes  in  88  per  cent,  of 


rxi]  TORSION   OF  TESTICLE  759 

cases,  according  to  Scudder.  The  tunica  vaginalis  is  filled  with 
blood-stained  fluid. 

Symptoms. — There  are  recurring  attacks  of  torsion  after  an 
injury  or  exertion,  or  occasionally  during  sleep  there  is  a  sudden 
attack  of  severe  pain  in  the  testicle,  extending  to  the  lower  part 
of  the  abdomen  and  even  to  the  loin.  Collapse  and  vomiting 
follow,  and  the  patient  is  pale  and  sweating,  with  a  drawn,  anxious 
expression.  The  temperature  may  be  subnormal  at  first,  but  is 
not  infrequently  raised  to  100°  or  102°  F.  after  a  few  hours.  The 
pulse  is  rapid,  abdominal  distension  has  been  observed,  and  con- 
stipation is  often  present.  There  may  be  a  history  of  an  imper- 
fectly descended  testicle,  and  not  infrequently  of  several  previous 
attacks  of  testicular  pain  and  swelling.  The  skin  over  the  testicle 
may  be  red  and  oedematous.  A  hard,  very  tender,  tense  swelling 
occupies  the  upper  part  of  the  scrotum  close  to  the  external 
abdominal  ring,  and  the  testicle  is  absent  from  the  scrotum. 
The  swelling  is  dull  on  percussion,  irreducible,  and  shows  no  impulse 
on  coughing  unless  a  hernia  is  present  above  the  testicle. 

The  attacks  may  last  for  one  or  several  days  and  then  pass 
off,  leaving  the  testicle  painful  and  tender,  and  after  a  time  the 
organ  atrophies. 

Less  severe  attacks  occur  in  some  cases,  and  gradual  atrophy 
of  the  testicle  follows  a  series  of  slight  attacks  of  pain  and  swelling. 
The  cord  is  felt  hard  and  tender  at  the  area  of  torsion. 

An  acute  attack  frequently  results  in  suppuration  or  gangrene 
of  the  testicle. 

The  number  of  attacks  varies.  In  a  case  under  my  care  a 
man  of  24  had  six  attacks  in  three  years,  only  one  of  which  lasted 
more  than  twenty-four  hours.  The  right  testicle  was  finally  a 
small,  round,  hard  body,  the  size  of  a  hazel-nut,  lying  near  the 
external  abdominal  ring. 

Diagnosis. — The  conditions  most  likely  to  be  mistaken  for 
torsion  of  the  cord  are  strangulated  hernia  and  inflammation  of 
the  lymphatic  glands  of  the  groin. 

In  strangulated  hernia  the  testicle  is  found  unaltered  and 
completely  descended,  collapse  and  vomiting  are  more  severe, 
and  constipation  absolute.  In  lymphadenitis  a  source  of  infection 
can  be  demonstrated,  the  testicle  and  cord  are  normal,  and  collapse, 
vomiting,  and  constipation  are  absent. 

Other  sources  of  difficulty  in  diagnosis  which  may  only  be  cleared 
up  by  operation  are  appendicitis  in  an  inguinal  hernia,  embolism 
of  the  spermatic  artery,  and  epididymo-orchitis  in  an  imperfectly 
descended  testicle. 

Treatment. — Manipulation  without  operation  has  been  sue- 


760  THE  TESTICLE  [chap,  lxi 

cessful  in  untwisting  the  cord  in  one  known  case.  At  an  early 
stage,  if  the  diagnosis  is  not  in  doubt  and  the  testicle  is  sufficiently 
descended  to  permit  of  the  necessary  manipulations,  an  attempt 
may  be  made  to  carry  out  this  treatment. 

In  the  great  majority  of  cases,  however,  immediate  operation 
is  necessary,  the  diagnosis  from  strangulated  hernia  being  in 
doubt  or  the  condition  of  the  patient  so  grave  that  radical  measures 
are  necessary.  The  testicle  may  be  exposed,  the  cord  untwisted, 
and  fixed  by  sutures.  In  the  majority  of  cases  orchidectomy  is 
necessary,  and,  if  a  hernia  is  present  also,  radical  cure  should  be 
carried  out.  In  chronic  cases  the  testicle  should  be  removed,  as 
atrophy  is  certain. 

LITERATURE 

Corner,  Male  Diseases  in  General  Practice.     1900. 

Cotte,  Lyon  Med.,  1911,  p.  758. 

Dowden,  Brit.  Med.  Journ.,  April  29,  1905. 

Edington,  Lancet,  June  25,  1904. 

Lexer,  Arch.  f.  klin.   Chir.,  1894,  p.  201. 

Low,  Trans.  Med.  Soc.  Lond.,  1908,  1909. 

Perry,  Birminglmm  Med.  Rev.,  1898,  p.  270. 

Scudder,  Ann.  of  Surg.,  1901,  p.  234. 

Taylor,  Brit.  Med.  Journ.,  Feb.  20,  1897. 

Van  der  Poel,  N.  Y.  Med.  Rec,  June  15,  1895. 


CHAPTER  LXII 


CONGENITAL     MALPOSITION  —  IMPERFECTLY 
DESCENDED  TESTICLE— ECTOPIA  TESTIS 

The  testicle  may  fail  to  descend  (Fig.  239),  or  may  partly  descend. 
Its  retention  in  the  abdomen  or  inguinal  canal  is  cryptorchism, 
which    may  be  miilateral  or 
bilateral.     The  testicle    may      I 
occupy  some  abnormal  posi- 
tion   not    in    the    track    of 
normal  descent — this  is  ecto- 
pia testis. 

Etiology. — I  mperfect 
descent  may  be  due  to  one 
or  to  several  factors. 

The  mesorchium  or  peri- 
toneal fold  may  be  adherent, 
or  it  may  be  too  long,  so 
that  the  organ  swings  loosely 
and  does  not  engage  in  the 
inguinal  canal.  The  spermatic 
vessels  or  vas  deferens  may 
be  short,  or  the  testicle  or 
epididymis  is  said  in  some 
cases  to  be  too  large  to  pass 
the  inguinal  canal.  Usually, 
however,  the  organ  is  small 
and  atrophied,  and  the  im- 
perfect descent  is  probably 
due,  in  part,  to  this.  The  de- 
velopment and  attachments  of  the  gubernaculum  testis  may  be 
deficient.  The  inguinal  canal,  abdominal  ring,  or  scrotum  may 
be  poorly  developed.  In  ectopia  testis  the  testis  is  drawn  into 
an  abnormal  position  by  the  fibres  of  the  gubernaculum  testis 
attached  in  that  area,  or  the  testicle  is  pushed  into  an  abnormal 
position  by  a  hernia. 

Pathological  anatomy. — The  testicles  are   normally  in   the 
scrotum  at  birth,  but  the  descent  may  be  delayed. 

761 


Fig.  239. — Undescended  testicle. 


762 


THE  TESTICLE 


[chap. 


A  retained  or  imperfectly  descended  testis  may  reach,  the 
scrotum  during  the  first  year,  but  after  that  time  it  will  not  do 
so.  In  infants  the  testicles  may  temporarily  disappear  and  return 
to  the  scrotum. 


Fig.  240. — Perineal  ectopia  of  left  testicle  (S.  G.  MacDonald's  case). 

Dukes  found  9  cases  of  imperfectly  descended  testis  in  2,000 
public-school  boys,  and  Corner  states  that  this  condition  was 
present  in  6-7  per  cent,  of  2,500  cases  of  inguinal  hernia  (children 
and  adults)  treated  at  St.  Thomas's  Hospital. 

The  right  side  is  slightly  more  often  affected  than  the  left. 


Lxii]      IMPERFECTLY   DESCENDED   TESTIS 


763 


In  imperfect  descent  the  organ  may  be  retained  within  the 
abdomen,  or  it  may  be  in  the  inguinal  canal,  or  at  the  external 
abdominal  ring  immediately  outside  the  canal. 

The  ectopic  testis  may  lie  in  the 
perineum  (Fig.  240),  Scarpa's  triangle, 
in  front  of  the  pubes,  or  on  the  abdo- 
minal wall  above  Poupart's  ligament. 

Eccles  considers  it  extremely  doubt- 
ful if  the  testis  is  ever  spontaneously 
passed  into  the  upper  part  of  the 
thigh  through  the  femoral  ring. 

The  communication  of  the  tunica 
vaginalis  with  the  peritoneal  cavity 
(processus  vaginalis)  is  usually  open. 

The  imperfectly  descended  testicle 
is  smaller  and  remains  infantile  in 
size  (Fig.  241),  but  it  is  also  said  to 
develop  to  its  proper  size  and  then 
become  atrophic. 

The  body  and  globus  minor  of  the 
epididymis  are  frequently  separated 
from  the  body  of  the  testicle  by  a 
broad  band  of  tissue,  the  mesorchium. 

In  structure  the  imperfectly  de- 
scended testicle  (Fig.  242)  shows  an 


Fig.  241. — Operation  spe- 
cimen of  imperfectly  de- 
scended testicle  and  hy- 
drocele surrounding  it. 

T.,    Poorly    developed    testicle.     E., 
Epididymis.      D.F.,    Vas     deferens. 

G.T..    Gubernaculum    testis.      T.V., 

Tunica  vaginalis. 


~.>., 


--.^ 


Fig.  242. — Section  of  undeveloped  imperfectly  descended  testicle. 


764  THE   TESTICLE  [chap. 

increase  in  the  fibrous  stroma,  the  tubules  are  smaller  and  fewer 
in  number,  and  spermatoblasts  and  spermatozoa  are  absent.  The 
interstitial  cells  of  the  testicle  are  present  and  fully  developed. 
The  scrotum  on  the  side  of  the  undescended  testis  is  frequently 
undeveloped  and  smooth,  the  dartos  muscle  being  absent.  Some- 
times, however,  it  is  normal  in  appearance,  and  only  smaller  in 
size  from  the  absence  of  the  testicle. 

Value  of  the  imperfectly  descended  and  ectopic  testicle. 
— The  testicle  is  incapable  of  producing  spermatozoa,  and  if  the 
abnormality  is  bilateral  the  individual  is  sterile.  To  this  there 
appear  to  be  a  few  exceptions,  spermatozoa  being  present  in  the 
seminal  fluid.  The  appearance  of  spermatozoa  in  these  cases  is 
delayed  to  the  age  of  20  or  22,  and  usually  lasts  only  one  or  two 
years.  Spermatozoa  have,  however,  been  found  in  rare  cases  as 
late  as  35  years  of  age.  Very  rarely  the  subjects  of  double 
cryptorchism  have  been  fertile.  In  these  cases  it  is  supposed 
that  the  imperfect  descent  results  from  obstruction  rather  than 
from  congenital  deformity. 

Of  27  cases  in  which  a  microscopical  examination  was  made 
the  testicle  was  ill-developed  and  atrophic  in  15,  apparently  normal 
with  spermatogenesis  in  10,  tuberculous  in  1,  and  malignant  in  1 
(Bawling). 

The  internal  secretion  of  the  testicle,  which  is  believed  to  be 
furnished  by  the  interstitial  cells,  is  not  abolished,  and  the  develop- 
ment of  manly  characteristics  is  not  necessarily  arrested.  The 
individual  may  be  fully  developed  and  virile. 

Symptoms. — The  great  majority  of  cases  seek  advice  on 
account  of  a  swelling  in  the  groin,  which,  on  examination,  is  found 
to  be  the  imperfectly  descended  testis  with  or  without  a  hernia. 
The  patient  (or  the  parents  if  the  patient  is  a  child)  is  usually 
aware  that  the  testicle  is  not  in  the  scrotum,  but  this  may  not 
have  been  noticed.  Pain  is  present  and  is  the  prominent  symp- 
tom in  about  25  per  cent,  of  cases.  It  may  be  moderate  and 
constant,  or  in  recurrent  attacks,  or  it  may,  less  frequently,  be 
very  severe. 

Complications.  1.  Inflammatory. — The  misplaced  testis  is 
subject  to  the  inflammatory  diseases  which  afiect  the  normally 
placed  organ.  Thus,  epididymitis  may  occur  in  gonorrhceal  and 
other  forms  of  urethritis  and  orchitis,  in  mumps,  and  the  organ  may 
become  the  seat  of  tuberculous  disease.  The  abnormal  position 
renders  it  especially  liable  to  traumatism,  and  recurrent  attacks  of 
inflammation  from  this  cause  are  common.  Adhesions  form  between 
the  testicle  and  the  external  abdominal  ring  and  render  the  testicle 
less  movable.     The  pain  is  usually  severe,   and  it  may  be  accom- 


Lxii]       IMPERFECTLY   DESCENDED  TESTIS         765 

panied  by  vomiting  and  collapse.  There  is  a  firm,  exquisitely 
tender  swelling  in  the  position  of  the  abnormally  placed  testis. 
Fluid  may  be  present  in  the  tunica  vaginalis,  and  fluctuation 
is  detected,  but  more  often  the  sac  is  tense  and  fluctuation 
cannot  be  obtained.  The  skin  may  be  unchanged,  or  red  and 
cedematous. 

Strangulated  hernia  or  acute  inflammation  of  lymphatic  glands 
of  the  groin  may  simulate  this  condition.  The  history  of  recurrent 
attacks  of  inflammation  and  the  absence  of  the  testicle  from  the 
scrotum  are  important  points  in  diagnosis.  The  general  symptoms 
are  seldom  so  severe  in  inflammation  of  the  misplaced  testis ;  the 
onset  is  more  gradual,  and  the  temperature  is  more  likely  to  be 
raised  than  in  strangulated  hernia,  where  the  onset  is  sudden,  the 
collapse  more  profound,  the  vomiting  more  severe,  and  the  con- 
stipation more  complete.  Local  pain  and  tenderness  are  more 
pronomiced  in  the  inflamed  testis.  The  diagnosis  from  inflamma- 
tion of  lymphatic  glands  in  the  groin  depends  upon  the  absence  of 
any  cause  of  lymphadenitis,  the  empty  scrotum,  the  position  of 
the  swelling,  and  the  history. 

After  the  attack  of  inflammation  has  subsided  the  testicle 
remains  tender,  and  eventually  atrophy  occurs  after  one  or  several 
attacks.  The  hydrocele  may  persist  after  the  inflammation  has 
subsided.  Suppuration  is  a  rare  complication  of  the  inflamed 
misplaced  testis. 

2.  Hernia. — Licomplete  closure  of  the  processus  vaginalis,  and 
consequent  hernia  of  the  abdominal  contents,  is  frequently  associated 
with  imperfect  descent  of  the  testis,  and  this  is  more  likely  to 
occur  when  the  testis  is  retained  in  the  inguinal  canal  than  if  it 
lies  at  the  external  abdominal  ring.  Corner  found  the  commmii- 
cation  open  in  80  per  cent,  of  200  cases.  In  these  cases  the  hernia 
usually  occurs  in  infancy  and  is  of  the  congenital  variety.  In  a 
few  cases  no  hernia  is  found.  The  most  frequent  form  of  hernia 
is  a  bubonocele ;  scrotal  hernia  is  less  common,  and  interstitial, 
crural,  and  perineal  hernias  are  rare.  Irreducible  hernia,  and 
very  rarely  strangulated  hernia,  have  been  noted. 

3.  New  growths. — Any  of  the  new  growths  that  affect  a  fully 
descended  testis  may  be  present  in  the  imperfectly  descended 
organ.  It  is  widely  believed  that  malignant  growths  (Fig.  243) 
more  often  affect  an  imperfectly  descended  than  a  normally  placed 
testis.  Eccles  found  that  of  40  cases  of  sarcoma  of  the  testis  the 
testicle  was  imperfectly  descended  in  only  1,  and  in  that  case 
it  was  retained  within  the  abdomen.  It  is  significant,  however, 
that  of  57  consecutive  cases  of  malignant  disease  of  the  testicle 
treated  at  the  London  Hospital,  Russell  Howard  found  that  9  were 


766 


THE  TESTICLE 


[chap. 


cases  of  retained  testis  (16  per  cent.) — an  unduly  large  propor- 
tion. Of  54  cases  of  malignant  disease  of  the  testicle  admitted 
to  the  Massachusetts  General  Hospital,  6  (11  per  cent.)  were  in 
imperfectly  descended  testicles  ;  and  Schadel  found  that  5  in  41 
cases  (12  per  cent.)  of  malignant  disease  were  in  partly  descended 
organs.     There  appears,  therefore,  to  be  some  foundation  in  fact 


Fig.  243. — Malignant  growth  of  imperfectly  descended  testicle. 

for  the  view  that  the  imperfectly  descended  testis  is  more  liable 
to  the  development  of  malignant  disease. 

The  majority  of  malignant  growths  which  affect  the  undescended 
testis  are  sarcomatous  in  nature,  while  those  found  in  the  normally 
placed  organ  are  more  frequently  epithelial  in  type.  The  round-, 
spindle-,  and  mixed- celled,  and  myxo-sarcoma,  are  the  varieties 
observed. 

4.  Torsion  of  the  cord. — This  condition,  which  is  considered 
elsewhere  (p.  758),  is  especially  frequent  in  association  with  im- 


Lxii]       IMPERFECTLY   DESCENDED  TESTIS        767 

perfect  descent  of  the  testis.     Torsion  may  take  place  when  the 
testicle  is  in  the  inguinal  canal  or  outside  the  external  ring. 

5.  Varicocele. — Occasionally  a  displaced  testicle  is  associated 
with  varicocele,  which  may  be  felt  underneath  the  skin.  I  have 
met  with  a  large  mass  of  varicose  veins  of  the  cord  protruding 
from  the  external  abdominal  ring  when  an  imperfectly  developed 
testis  occupied  the  inguinal  canal  above  it. 

6.  General  changes  and  concomitant  malformations. — 
When  both  testicles  are  imperfectly  descended  and  badly  developed 
the  general  development  of  the  body  is  likely  to  be  affected.  This 
is  dependent  upon  the  absence  of  the  internal  secretion  of  the 
testis.  If  the  imperfectly  descended  testes  are  well  developed,  or 
one  only  is  affected,  there  is  no  lack  of  growth.  Other  congenital 
deformities  may  be  present,  such  as  cleft  palate,  hare-lip,  spina 
bifida,  talipes,  absence  of  one  kidney,  ectopia  vesicae,  hypospadias, 
cleft  scrotum,  etc. 

Treatment. — The  testicle  should  not  be  left  undisturbed,  even 
where  it  is  giving  rise  to  no  inconvenience  at  the  time  of  the 
examination.  The  tendency  of  the  development  of  hernia,  the 
certainty  of  recurrent  attacks  of  inflammation,  the  imperfect 
development  or  atrophy  of  the  organ,  the  possibility  of  infection 
and  of  torsion,  and  the  predisposition  to  the  development  of 
malignant  disease,  all  render  operative  interference  imperative. 

Operation  consists  in  (1)  placing  the  testis  in  the  scrotum, 
or  (2)  replacing  the  organ  in  the  abdomen,  or  (3)  removing  the 
testicle. 

If  both  testicles  are  retained  within  the  abdomen  operation 
is  unnecessary.  In  such  cases  single  or  double  inguinal  hernia  may 
be  present,  and  operation  for  the  radical  cure  of  hernia  becomes 
necessary.  During  this  operation  search  should  be  made  for  a 
small  testicle  in  the  inguinal  canal  which  may  have  escaped 
observation.  If  such  a  testicle  is  found  it  should  be  returned  to 
the  abdomen  if  its  fellow  is  retained,  or  removed  if  the  second 
organ  is  normal  and  descended. 

If  both  testicles  are  partly  descended  an  attempt  to  bring  them 
down  into  the  scrotum  by  operation  should  only  be  made  when 
there  appears  to  be  some  prospect  of  success,  the  structures  of  the 
cord  allowing  a  fair  degree  of  downward  excursion.  Failing  this, 
the  testicles  should  be  replaced  within  the  abdomen.  It  is  known 
that  the  testicle  in  these  cases  does  not  furnish  active  spermatozoa, 
but  the  internal  secretion  of  the  organ  is  usually  active  and  is 
preserved.  Corner  recommends  that  the  testicle  be  placed  in  the 
scrotum  on  one  side  and  replaced  in  the  abdomen  on  the  other. 

Where  one  testicle  is  fully  descended  and  the   other  is  only 


THE  TESTICLE  [chap. 

imperfectly  descended  an  attempt  may  be  made  to  place  the  latter 
in  the  scrotum  and  retain  it  there.  In  the  majority  of  cases,  how- 
ever, it  will  be  better  to  remove  the  partly  descended  testicle  at 
once  and  close  the  inguinal  canal.  The  necessity  for  this  course 
depends  upon  the  recurrent  attacks  of  inflammation  due  to  trivial 
causes,  the  eventual  destruction  of  the  testicle  by  fibrosis,  the 
development  of  hernia — all  of  which  are  certain  to  occur  if  the 
testicle  is  left  untouched. 

The  age  at  which  operation  for  partly  descended  testicle  should 
be  undertaken  would  be  after  the  fourth  year  and  before  puberty. 
The  best  age  for  operation  is  from  8  to  10  years. 

1.  Orchidopexy  consists  in  placing  the  testicle  in  the  scrotum 
and  fixing  it  there.  An  incision  is  made  from  a  little  below  the 
external  abdominal  ring  along  the  line  of  the  inguinal  canal  to 
within  an  inch  of  the  anterior  superior  iliac  spine.  The  external 
ring  is  defined  and  the  external  oblique  aponeurosis  split  as  far 
as  the  internal  ring.  The  peritoneal  sac  is  now  examined.  If 
the  communication  between  the  tunica  vaginalis  and  the  peritoneal 
cavity  remains  open,  this  must  be  cut  across  just  above  the  testicle 
and  the  lower  end  closed  to  form  a  tunica  vaginalis,  while  the  upper 
end,  or  the  hernial  sac  if  the  communication  has  already  closed,  is 
dissected  from  the  structures  of  the  cord  and  ligatured  at  the 
internal  ring.  The  testicle  should  now  be  thoroughly  freed  from 
all  adhesions  and  the  cord  put  upon  the  stretch.  Steady,  firm 
traction  may  considerably  lengthen  the  cord.  Bands  of  adhesions 
of  the  cord,  strands  of  cremasteric  muscle,  and  the  coverings  of  the 
cord  should  be  sacrificed  in  attempting  to  elongate  the  pedicle. 
In  order  to  permit  further  elongation,  some  of  the  veins  of  the  cord 
may  be  ligatured  and  cut  across,  the  vas  deferens,  its  artery  and 
vein,  being  preserved.  The  epididymis  may  be  separated  from 
the  testicle  as  high  as  the  globus  major  and  the  testicle  turned 
upside  down.  The  scrotum  is  now  prepared  for  the  reception 
of  the  testicle  by  introducing  the  finger  or  a  pair  of  dissecting 
forceps  into  it  from  the  inguinal  wound.  The  testicle  is  then 
sutured  to  the  bottom  of  the  scrotum  by  invaginating  the  scrotum 
with  the  finger  and  suturing  the  testicle  with  silk,  or  a  silk  thread 
may  be  passed  through  the  scrotum  from  without,  carried  through 
the  tunica  albuginea,  and  through  the  scrotum  again  from  within 
outwards,  and  tied  over  a  small  pad  of  lint  or  gauze,  or  the  ends 
may  be  attached  to  a  wire  cage  fixed  to  the  perineum.  Corner 
recommends  that  a  flap  of  tunica  vaginalis  and  tunica  albuginea 
be  turned  down  from  the  lower  pole  of  the  testicle  and  sutured 
to  the  scrotum.  The  inguinal  canal  is  now  repaired  as  in  a  hernia 
operation,  and  the  cord  sutured  to  the  external  abdominal  ring. 


Lxii]        IMPERFECTLY   DESCENDED   TESTIS        769 

Mamourian,  after  opening  the  parietal  layer  of  the  tunica 
vaginalis,  makes  an  opening  at  the  lower  end  of  the  scrotum  and 
draws  the  loose  membrane  through,  stitching  it  with  a  purse- 
string  suture  so  that  a  tuft  projects. 

If  the  testicle  cannot  be  implanted  in  the  scrotum  without 
tension,  the  operation  should  be  abandoned  and  the  organ 
removed. 

Results. — The  imperfectly  descended  testicle  is  small,  and  it 
remains  small  after  it  has  been  transplanted  into  the  scrotum. 
There  is  a  tendency  for  the  testicle  to  ascend  again  after  this 
operation.  It  is  doubtful  if  the  spermatogenetic  function  of  a 
small  transplanted  testicle  becomes  active,  although  there  appears 
to  be  some  evidence  in  support  of  this  having  occurred  in  a  few 
cases.     The  internal  secretion  is  preserved. 

In  40  cases  of  attempted  scrotal  placement  Kawhng  had  4  fair 
results,  3  promised  unfavourably,  8  were  not  traced,  25  were 
failures.  From  these  results  he  regards  scrotal  placement  as 
doomed  to  failure  from  the  beginning. 

In  perineal,  pubic,  and  crural  ectopia  an  attempt  may  be  made 
to  place  the  testicle  in  the  scrotum.  Should  these  operations  fail, 
orchidectomy  should  be  performed. 

2.  Replacement  of  the  testicle  in  the  abdomen.  —  The 
object  of  this  operation  is  to  save  the  internal  secretion  of  the 
testicle.  It  is  indicated,  therefore,  in  bilateral  cryptorchism  before 
puberty.  It  is  known  that  whatever  spermatogenetic  function, 
the  testicle  may  possess  is  lost  after  being  retained  in  the  abdomen 
for  some  time.  Rare  cases  of  paternity  in  double  retained  testis 
(cryptorchid)  are  known. 

After  the  inguinal  canal  has  been  opened  the  testicle  is  placed 
in  a  bed  in  the  extraperitoneal  tissue  and  retained  by  a  suture. 
The  inguinal  canal  is  then  closed.  The  testicle  may  be  placed 
within  the  peritoneal  cavity,  but  cases  of  torsion  of  the  cord  have 
been  known  to  occur  after  this  operation. 

3.  Orchidectomy. — This  is  performed  if  one  testicle  is  fully 
descended  and  the  second  imperfectly  descended  and  atrophied. 
The  testicle  is  dissected  as  before,  the  cord  ligatured,  and  the 
inguinal  canal  closed. 

LITERATURE 

Bland-Sutton,  Pract.,  1910,  p.  19. 
Cautwell,  Amcr.  Jouni.  of  Surg.,  1909,  p.  322. 
Coley,  Ann.  d/  Surg.,  Sept.,  1908. 
Corner,  3Iale  Diseases  of  General  Practice.     1910. 
Eccles,  McAdam,   The   Imperfecthj  Descended  Testis.     1903. 
Howard,  Russell,  Pract.,  1907,  p.  794. 
Mamourian,  Lancet,  1909,  i.  157. 
'2x 


770  THE   TESTICLE  [chap,  lxii 

LITERATURE  (continued) 

Moschkowitz,  Anji.  of  Surg.,  Dec,  1910. 
Rawling,  Pract.,  Aug.,  1908. 
Raymond,  Amer.  Journ.  of  Urol.,  Sept.,  1909. 
Zacharias,  Arch.  f.  Gyn.,  1909,  p.  506. 

INVERSION  OF  THE  TESTICLE 

The  fully  descended  testicle  may  be  displaced  within  the 
scrotum.  In  the  usual  displacement  the  free  border  of  the  organ 
looks  backwards  and  the  epididymis  lies  in  front.  Less  fre- 
quently the  free  border  faces  downwards  and  the  long  axis  is 
horizontal.  Reversion  of  the  testicle  has  been  described,  the  upper 
pole  being  directed  downwards  and  the  vas  deferens  being  attached 
to  the  tail  of  the  epididymis,  which  was  at  the  upper  part  of  the 
organ.  These  congenital  displacements  are  of  importance  in 
tapping  a  hydrocele  and  in  other  operations  on  the  testicle. 


CHAPTER  LXIII 

INFLAMMATION  OF  THE  EPIDIDYMIS  AND 
TESTICLE 

Inflammation  of  the  testicle  or  epididymis  may  follow  injury, 
but  the  two  chief  paths  of  infection  are  the  urethra  and  vas  deferens 
and  the  blood  stream.  In  the  two  former  the  epididymis  is  affected, 
while  in  the  latter  the  testicle  is  usually  involved.  In  the  majority 
of  cases  the  epididymis  is  first  affected  (epididymitis).  The  testicle 
may  be  affected  by  spread  of  the  inflammation  (epididymo-orchitis). 
Less  frequently  the  testicle  is  affected  alone  (orchitis). 

EPIDIDYMITIS 

This,  the  most  common  form  of  inflammation  of  the  testis, 
may  be  acute  or  chronic.  It  occurs  at  any  age,  but  is  most  fre- 
quent in  early  adult  life. 

Etiology. — Epididymitis  may  follow  an  injury,  such  as  a  blow 
or  a  kick,  or  may  develop  from  a  metastatic  deposit  in  acute  specific 
fevers  such  as  smallpox,  but  in  the  great  majority  of  cases  it  takes 
ori^n  in  a  urethral  infection.  Gonorrhoea  is  the  most  frequent 
cause,  •  the  epididymitis  appearing  in  the  third  or  fourth  week  of 
the  disease  in  20  per  cent,  of  cases.  Less  frequently  epididymitis 
develops  as  a  complication  of  old-standing  chronic  inflammation  of 
the  prostatic  urethra  following  gonorrhoea.  The  passage  of  instru- 
ments in  stricture  of  the  urethra  or  enlargement  of  the  prostate, 
lithotrity,  prostatectomy,  and  the  use  of  strong  instillations  in 
posterior  urethritis  are  common  causes.  Chronic  infection  of  the 
bladder,  prostate,  and  prostatic  urethra  of  non-gonorrhoeal  origin, 
such  as  bacillus  coli  infection,  may  give  rise  to  acute  epididymitis 
without  any  obvious  exciting  cause. 

Pathology. — The  infection  reaches  the  epididymis  by  spread 
along  the  lumen  of  the  vas  deferens,  or  in  some  cases  along  the 
lymphatic  vessels  of  the  cord.  Rarely,  as  in  acute  specific  fevers, 
the  blood  stream  is  the  path  of  infection. 

In  severe  acute  epididymitis  the  whole  of  the  epididymis  is 
involved,  and  forms  a  large  mass  in  which  the  testicle  is  embedded. 
In  less  severe  cases  the  tail  only  of  the  epididymis  is  affected.     The 

771 


772  THE  TESTICLE  [chap. 

enlargement  is  due  to  inflammatory  exudation  around  and  between 
the  convolutions  of  the  duct  of  the  epididymis  ;  small  cavities 
filled  with  pus  are  formed  in  localized  dilatations  of  the  ducts. 
The  walls  of  the  duct  are  infiltrated,  the  epithelium  is  shed,  and. 
the  lumen  contains  a  mixture  of  pus,  epithelium,  and  spermatozoa. 
The  tunica  vaginalis  contains  a  moderate  amount  of  fluid  in  about 
one-third  of  the  cases.  The  vas  deferens  is  thickened  and  inflamed 
and  denuded  of  epithelium,  and  contains  pus.  There  may  be  red- 
ness and  oedema  of  the  scrotum. 

When  the  acute  attack  has  subsided  the  swelling  and  tender- 
ness disappear.  Not  infrequently,  however,  a  nodular  fibrous 
thickening  at  the  tail  of  the  epididymis  may  persist  for  many 
years  or  remain  permanently. 

Symptoms. — There  is  for  some  hours  or  one  or  two  days  dull, 
heavy  aching,  and  the  epididymis  and  cord  are  tender.  In  severe 
cases  this  is  followed  by  an  initial  rigor,  the  temperature  rises  to 
101°  or  102°  F.,  and  the  pain  becomes  severe  and  sickening  in 
character.  Dragging  pain  along  the  cord,  severe  pain  along  the 
inguinal  canal  and  in  the  lower  abdomen,  and  pain  in  the  loins 
are  often  experienced.  Nausea  and  sickness  are  not  uncommon. 
The  epididymis  rapidly  becomes  swollen  and  forms  a  large,  very 
tender  mass,  in  the  front  of  which  the  testicle  is  embedded.  It 
attains  its  full  size  in  from  two  to  three  days,  and  then  remains 
.stationary.  Some  fluid  can  usually  be  detected  in  the  tunica 
vaginalis,  and  the  skin  of  the  scrotum  is  red  and  oedematous. 
There  is  tenderness  of  the  cord  and  along  the  line  of  the  inguinal 
canal,  and  the  vas  is  felt  per  rectum  to  be  thickened  and  tender. 
The  acute  symptoms  continue  for  from  five  to  eight  days  and  then 
gradually  subside,  and  the  temperature  returns  to  normal  in  ten 
Or  fourteen  days  from  the  onset.  The  enlargement  of  the  epi- 
didymis subsides  slowly,  lasting  from  fourteen  days  to  four  or  six 
weeks,  and  it  may  persist  as  a  nodule  at  the  tail  of  the  organ. 
When  a  urethral  discharge  has  been  present  before  the  onset  of 
tihe  epididymitis  it  disappears,  and  only  reappears  when  the  epi- 
didymitis subsides.  Epididymitis  may  be  bilateral,  but  the  in- 
flammation in  one  epididymis  has  partly  or  completely  subsided 
before  the  other  is  affected ;  double  simultaneous  epididymitis  is 
very  rare.  The  extent  to  which  the  testicle  proper  is  involved, 
so  far  as  it  can  be  estimated  clinically,  is  very  small  in  the  majority 
of-  cases.  When  it  is  not  concealed  by  an  acute  hydrocele  the 
testicle  is  found  to  remain  michanged  in  size  and  consistence,  and 
is  not  tender.  In  a  few  cases  it  shares  in  the  inflammation,  and 
is  tense,  tender,  and  exquisitely  painful  (epididymo-orchitis). 

Complications    and    sequelae.— In  epididymitis   secondary 


Lxiii]  EPIDIDYMITIS  773 

to  urethral  disease  there  is  invariably  infection  of  the  prostatic 
urethra.  Acute  prostatitis  not  infrequently  precedes  the  onset  of 
epididymitis,  but  the  prostate  may  escape.  Seminal-vesiculitis 
is  often  present.  Abscess  formation  is  an  unusual  complication  of 
epididymitis.  Very  rare  in  gonorrhoeal  epididymitis,  it  is  more 
frequent  in  the  form  which  results  from  other  infections,  such 
as  epididymitis  complicating  stricture,  enlarged  prostate,  etc.  The 
abscess  may  form  either  at  the  head  or  at  the  tail  of  the  epi- 
didymis. The  scrotum  is  red  and  oedematous,  and  the  epididymis 
quickly  becomes  adherent.  The  skin  becomes  thin  and  glazed, 
and  the  abscess  ruptures  on  the  surface.  After  discharging  for 
a  week  or  more  the  sinus  heals,  and  when  the  epididymitis  has 
subsided  a  fibrous  track  remains,  binding  a  dimpled  scar  on  the 
surface  of  the  scrotum  to  the  epididymis. 

A  fibrous  nodule  may  persist  after  acute  epididymitis,  and  is 
usually  situated  at  the  tail.  ObUteration  of  the  lumen  of  the 
epididymal  duct  at  this  point  is  not  infrequently  the  result.  When 
this  is  bilateral,  or  when  the  second  testicle  is  imperfectly  developed 
or  atrophied,  sterility  results.  Benzla  found  that  in  soldiers  of 
the  German  army  who  .had  suffered  from  gonorrhoea  10-5  per 
cent,  of  those  who  had  not  had  epididymitis  were  childless,  while 
of  those  who  had  suffered  from  unilateral  and  from  bilateral 
epididymitis  the  percentages  were  respectively  23-4  and  41-7. 
Atrophy  of  the  testicle  does  not  follow  epididymitis  when  there 
has  been  no  orchitis. 

Tuberculous  disease  is  stated  to  be  a  sequel  of  acute  gonor- 
rhoeal epididymitis.  This  is  not,  however,  my  experience.  The 
acute  epididymitis  which  occasionally  precedes  chronic  tuberculosis 
of  the  testicle  is  tuberculous  in  nature. 

Treatment. — In  the  early  stage  it  will  be  impossible  to  fore- 
tell the  severity  of  the  attack,  and  the  patient  should  in  all  cases 
be  confined  to  bed.  Calomel,  4  gr.,  is  given,  followed  by  a  smart 
saline  purge,  while  local  treatment  of  the  urethra,  if  this  has 
preceded  the  attack,  should  at  once  be  discontinued.  A  low  diet 
should  be  prescribed,  with  plenty  of  fluid,  and  if  the  pain  is  severe 
a  hypodermic  injection  of  morphia  should  be  given.  The  scrotum 
should  be  supported ;  this  may  be  done  by  means  of  a  well-fitting 
suspender  or  by  a  sand-bag  or  cushion  of  wool  or  other  material 
placed  between  the  thighs,  or  by  slinging  the  scrotum  in  a  tri- 
angular bandage,  the  base  of  which  is  carried  transversely  below 
the  scrotum  and  the  ends  tied  to  a  waistband,  while  the  apex  is 
brought  forwards  over  the  scrotum  and  penis  and  folded  over 
the  waistband  in  the  middle  Une,  a  slit  being  made  through 
which  the  penis  protrudes.     The  testicle  may  also  be  supported 


774  THE  TESTICLE  [chap. 

on  a  piece  of  adhesive  plaster,  4  in.  wide,  carried  across  from  thigh 
to  thigh,  or  a  well-padded  tray  of  cardboard  may  be  made,  with 
a  semicircle  cut  out  of  the  upper  border  to  embrace  the  base  of 
the  scrotum,  and  slung  round  the  waist. 

During  the  first  twenty-four  or  thirty-six  hours  a  small  bag 
of  finely  crushed  ice  applied  to  the  testicle  gives  great  relief.  If 
this  is  not  obtainable  or  is  unsuccessful  in  relieving  pain,  and  in 
any  case  after  the  first  few  hours,  hot  fomentations  of  boric  lotion, 
or  lead  and  opium  lotion,  should  be  applied,  and  changed  every 
hour  or  two  hours.  Extract  of  belladonna  in  glycerine  (equal 
parts)  may  be  painted  over  the  scrotum,  and  fomentations  applied 
over  this. 

Guaiacol  has  been  recommended  in  the  acute  stage.  An  oint- 
ment containing  6-10  per  cent,  is  applied  daily,  care  being  taken 
not  to  cause  dermatitis.  Tucker  recommends  the  local  application 
of  a  saturated  solution  of  magnesium  sulphate  on  gauze  kept 
constantly  wet  with  the  solution.  The  following  ointment  is 
recommended  by  Maurange :  Methyl  salicylate  20  parts,  guaiacol 
2|  parts,  lanoline  15  parts,  vaseline  25  parts  ;  this  is  applied  after 
shaving  the  scrotum,  and  is  covered  with  cotton-wool,  a  double 
spica  woollen  bandage  being  then  applied  over  all.  Painting  the 
scrotum  with  nitrate  of  silver  solution,  10  per  cent.,  has  been 
found  useful.  If  acute  hydrocele  is  present  some  relief  of  pain 
may  be  obtained  by  tapping  it  with  a  fine  trocar. 

Puncture  of  the  testicle,  at  one  time  much  in  vogue,  is  now 
abandoned. 

When  the  pain  and  tenderness  in  a  severe  attack  have  subsided 
the  fomentations  may  be  discontinued.  In  this  and  the  later 
stages  potassium  iodide  given  internally  and  applied  locally  as  an 
ointment  (half  strength  of  the  unguentum  potassii  iodidi,  B.P.) 
is  of  considerable  value.  lothion  (containing  80  per  cent,  iodine 
with  equal  parts  of  lanoline  and  vaseline)  has  been  recommended. 

The  time  during  which  the  patient  is  confined  to  bed  varies 
with  the  severity  of  the  attack  ;  from  ten  to  fourteen  days  is 
usual  in  a  moderately  severe  attack.  The  application  of  a  Julien 
suspender,  by  which  pressure  may  be  applied  by  means  of  packing, 
enables  the  patient  to  get  about  sooner  when  this  is  imperative. 
A  relapse  of  the  epididymitis  is  not  uncommon  if  the  patient  is 
allowed  to  leave  his  bed  too  soon ;  this  should  be  guarded  against. 

Operative  treatment  of  acute  epididymitis  has  been  recom- 
mended by  various  observers.  Bazet  advised  epididymotomy  and 
packing  of  the  wound  with  ichthyol  and  glycerine  (10  per  cent.), 
and  Belfield  advocated  incision  and  drainage.  Baernamann  in  1903 
treated  28  cases  by  puncture. 


xxm]  CHRONIC   EPIDIDYMITIS  775 

Hagner  makes  an  incision  2  in.  long  at  the  junction  of  the 
testicle  and  epididymis,  and  opens  the  tmiica  vaginalis.  The 
testicle  and  epididymis  are  delivered,  and  the  epididymis  punc- 
tm-ed  in  many  places  with  a  knife.  If  pus  escapes  the  opening 
is  enlarged  and  the  cavity  washed  out  with  antiseptic  solution 
by  means  of  a  fine-pointed  syringe.  The  tunica  vaginalis  is  washed 
and  drained.  The  womid  heals  in  ten  days.  Hagner  operated 
in  25  cases,  and  claims  that  the  pain  at  once  disappears  and  the 
duration  of  the  disease  is  shortened. 

Puncture  of  the  inflamed  epididymis  with  a  hypodermic  needle 
has  also  been  advocated. 

In  the  subacute  stage  strapping  the  testicle  is  sometimes 
employed.  This  is  carried  out  by  a  number  of  short  strips  of 
adhesive  plaster  applied  from  behind  forwards  and  from  above 
downwards,  and  crossing  each  other  along  the  front  of  the 
testicle.  The  first  strip  confines  the  testicle  to  the  lower  extremity 
of  the  scrotum,  the  others  apply  gentle  pressure  over  it. 

Eecurrent  attacks  of  acute  epididymitis  may  complicate  catheter 
life  in  cases  of  enlargement  of  the  prostate  or  other  conditions 
where  sepsis  is  present  in  the  deep  urethra.  Where  other  methods 
of  treatment  have  failed  vasectomy  has  been  practised  with  success. 

In  chronic  epididymitis  the  inflammatory  nodule  is  situated 
at  the  lower  end  of  the  epididymis.  This  may  be  bilateral,  or 
the  second  testicle  may  be  poorly  developed  and  azoospermia 
results.  In  sterile  marriages  the  fault  lies  with  the  male  partner 
in  over  15  per  cent,  of  cases,  and  in  a  large  number  of  these  there  is 
azoospermia  due  to  chronic  epididymitis  of  the  globus  minor. 

For  such  cases  Martin  has  introduced  the  operation  of  epi- 
didymo-vasotomy,  by  which  an  anastomosis  is  formed  between 
the  vas  deferens  and  the  head  or  upper  end  of  the  epididymis. 
The  testicle  is  exposed  and  delivered  from  the  scrotum  and  the 
head  of  the  epididymis  and  the  adjacent  portion  of  the  vas  exposed 
by  incising  the  coverings  of  the  testicle.  The  most  convenient 
method  is  to  open  the  tunica  vaginalis,  when  the  globus  major 
will  be  found  hang  in  the  cavity  at  the  upper  pole  of  the  testicle. 
The  vas  is  drawn  through  an  opening  in  the  tunica  vaginalis  at  the 
level  of  the  globus  major.  A  portion  of  this  part  of  the  epididymis 
is  excised,  when  a  milky  fluid  will  ooze  from  the  cut  surface  ;  this 
contains  motile  spermatozoa.  The  vas  is  incised  longitudinally 
and  its  lumen  opened  ;  the  edges  of  this  incision  are  stitched  to 
the  edges  of  the  wound  in  the  epididymis.  Martin  used  fine  silver 
wire  ;  I  have  found  fine  catgut  sufficient  for  the  purpose,  but  the 
silver  wire  is  preferable,  as  it  passes  readily  through  the  eye  of 
the  finest  needle.     The  operation  requires  delicacy  of  touch,  but 


776  THE   TESTICLE  [chap. 

presents  no  great  difficulty.  The  needles  must  be  rounded  and 
very  fine,  as  the  wall  of  the  vas  cuts  very  easily.  Before  under- 
taking the  operation  the  urethra,  prostate  and  seminal  vesicles 
must  be  examined,  and  any  disease  of  these  organs — such  as  stric- 
ture, chronic  prostatitis,  or  seminal-vesicuhtis — treated.  Where 
there  is  chronic  prostatitis  of  a  severe  grade  the  operation  is  contra- 
indicated,  as  it  is  certain  that  it  would  be  unsuccessful. 

Martin  records  several  cases.  I  have  performed  the  operation 
in  five  cases.  Motile  spermatozoa  have  been  found  in  the  seminal 
fluid  after  the  operation  where  previously  azoospermia  existed. 

LITERATURE 

Baernamann,  Deuts.  med.  Woch.,  1903,  No.  40. 

Bazet,  Amer.   Journ.  of  Urol.,  May,  1906. 

Benzla,  Arch.  f.  Derm.  u.  Syph.,  1898,  p.  33. 

Ernst,  Berl.  Bin.  Woch.,  March  8,  1909. 

Hagner,  Ann.  of  Surg.,  1908. 

Martin,   Vniv.  of  Pennsylvania  Med.  Bull.,  March,  1902. 

Therap.  Gaz.,  Dec.  15,  1909. 
Tucker,  Therap.  Gaz.,  April,  1907. 

OECHITIS 

In  orchitis  there  is  inflammation  of  the  testicle  proper.  This 
may  be  combined  with  epididymitis,  or  it  may  follow  an  attack 
of  epididymitis  (epididymo-orchitis),  but  more  frequently  it  occurs 
independently. 

Etiology.  —  A  urethral  form  of  epididymo-orchitis  following 
gonorrhoea  or  compHcating  stricture,  enlarged  prostate,  etc.,  is 
rarely  observed.  Injury,  such  as  from  a  blow  or  a  kick,  is 
the  most  frequent  cause.  Orchitis  occurred  in  5-6  per  cent,  of 
cases  of  operation  for  varicocele  recorded  by  Corner  and  Nitch. 
Orchitis  is  the  form  of  inflammation  of  the  testis  which  follows 
metastatic  infection,  as  in  mumps,  typhoid  fever,  smallpox, 
scarlet  fever,  influenza,  malaria,  and  tonsillitis.  The  pain  is 
usually  severe,  but  it  may  be  a  dull,  persistent  aching  radiating 
along  the  cord  and  into  the  loin  and  back.  The  testicle  is 
enlarged,  very  tender,  and  may  sometimes  reach  the  size  of  a 
goose's  egg.  It  is  smooth,  firm,  and  of  uniform  consistence,  and 
the  epididymis  can  be  felt  on  its  posterior  aspect.  The  tem- 
peratm^e  is  raised,  and  occasionally  there  is  high  fever. 

There  is  no  difficulty  in  diflerentiating  orchitis  from  epididy- 
mitis by  palpation.  Hydrocele  is  excluded  by  the  absence  of 
translucency. 

Symptoms. — In  mumps  the  testicle  becomes  affected  about 
the  sixth  or  eighth  day,  when  the  swelling  of  the  glands  is  sub- 
siding.    It  occurs  in  boys  and  yomig  adults,   and  is  extremely 


LxiiiJ  ORCHITIS  777 

rare  in  childhood  and  old  age.  I  have  seen  a  case  of  orchitis  of 
this  nature  in  a  man  of  58  years  in  whom  the  general  symptoms 
were  very  pronounced,  and  the  local  symptoms  comparatively 
insignificant.  In  23  cases  of  mumps  in  an  infantry  battalion 
Kocher  found  7  complicated  with  orchitis,  and  at  the  same  time 
there  were  4  cases  of  primary  orchitis.  Orchitis  occurred  in  9  out 
of  23  cases  of  mumps  in  schoolboys  observed  by  Dukes.  The 
onset  of  orchitis  is  preceded  by  a  rise  of  temperature.  The  testicle 
is  moderately  enlarged  and  tender.  The  amount  of  pain  varies  ; 
it  may  be  shght  or  very  severe.  The  epididymis  and  cord  escape. 
After  about  four  days  the  swelling  subsides  and  quickly  dis- 
appears. The  second  testicle  may  be  attacked  when  the  inflam- 
mation in  the  first  is  subsiding.  In  some  cases  the  swelUng  of 
the  salivary  glands  is  slight ;  in  the  case  just  related  it  had  been 
overlooked  until  close  cjuestioning  elicited  a  history  of  sUght 
swelling.  In  some  epidemics  of  mumps  orchitis  has  occurred  when 
no  trace  of  swelling  of  the  salivary  glands  could  be  found.  In  such 
cases  high  fever  and  marked  nervous  symptoms  may  be  present. 

Atrophy  of  the  testicle  follows  in  a  considerable  proportion  of 
cases.  It  is  more  frequent  after  the  orchitis  of  mumps  than  in 
any  other  form ;    Kocher  fomid  it  in  over  one-third  of  such  cases. 

Typhoid  orchitis  may  occur  during  the  course  or  convalescence 
of  the  disease,  the  latter  being  the  more  frequent.  There  is  a  rise 
of  temperature,  and  occasionally  a  rigor.  The  local  symptoms  may 
be  slight,  and  the  course  is  usually  rapid.     Atrophy  is  a  rare  sequel. 

Orchitis  occurring  during  other  specific  fevers  requires  no 
special  description. 

Hydrocele  is  absent  in  orchitis.  Suppuration  is  not  infrequent 
in  orchitis  complicating  specific  fevers.  When  the  temperature 
remains  high  and  the  testicle  enlarged  and  tender,  the  formation 
of  an  abscess  may  be  suspected. 

Treatment  is  similar  to  that  of  epididymitis.  Puncture  of 
the  testicle,  at  one  time  largely  practised,  is  now  abandoned. 
When  an  abscess  is  suspected  an  incision  into  the  body  of  the 
testicle  should  be  made  ;  protrusion  of  the  testicular  gland  tissue 
together  wdth  inflammatory  material  (hernia  testis)  frequently 
follows.  With  antiseptic  dressing  and  pressure  applied  with  adhe- 
sive strapping  this  will  heal. 

LITERATUEE 

Corner  and  Nitch,  Brit.  Med.  Journ.,  1906,  i.  191. 
Dukes,  Lancet,  1906,  i.  861. 
Higgens,  Brit.  Med.   Journ.,  April  18,  1908. 
Maidlow,  Brit.  Med.  Journ.,  April  25,  1908. 
Waish,  Brit.  Med.  Journ.,   May  30,  1908. 


CHAPTER  LXIV 
SYPHILIS  OF  THE    EPIDIDYMIS  AND  TESTICLE 

SYPHILITIC   EPIDIDYMITIS 

The  epididymis  is  rarely  affected.  Two  forms  of  syphilitic  epi- 
didymitis have,  however,  been  observed  :  (a)  In  the  secondary,  or 
sonietimes  in  the  tertiary  period,  a  subacute  or  chronic  epididymitis 
develops  in  the  globus  maj  or  and  may  spread  over  the  whole 
of  the  organ.  The  globus  minor  is  rarely  affected,  nor  is  the  body 
of  the  testis  involved.  The  swelling  is  hard  and  painless,  and 
usually  bilateral,  and  appears  in  the  third  or  fourth  month,  some- 
times at  a  later  date,  (b)  Small  gummata  are  in  rare  cases  found 
in  the  epididymis  in  the  tertiary  stage.  The  diagnosis  of  syphilitic 
epididymitis  is  made  by  the  absence  of  urethral  disease,  the  slow, 
painless  development,  the  history  of  syphilis  and  the  effect  of 
antisyphilitic  treatment. 

SYPHILITIC   ORCHITIS 

Syphilitic  orchitis  occurs  during  the  tertiary  stage,  usually  two 
or  three  years  after  the  infection,  rarely  at  an  earlier  period  (four 
to  six  months).  It  either  takes  a  diffuse  form  or  develops  as  a 
localized  gumma.  Active  syphilitic  lesions  may  be  present  when 
the  syphilitic  orchitis  develops,  or  the  affection  of  the  testicle 
may  be  the  solitary  manifestation  of  syphilis. 

Pathology. — In  the  diffuse  form  the  tunica  albuginea  be- 
comes thickened  at  different  spots,  and  there  is  effusion  of  fluid 
into  the  tunica  vaginalis.  The  inflammatory  thickening  spreads 
to  the  fibrous  framework  of  the  testicle,  which  is  at  first  densely 
infiltrated;  later  fibrous  tissue  forms.  Contraction  of  the  newly 
formed  fibrous  tissue  causes  atrophy  of  the  testicle.  Only  part  of 
the  testicle  may  be  affected,  but  usually  the  whole  organ  is  involved. 

The  testicle  on  section  is  firm  and  may  be  hard.  The  thickened 
fibrous  septa  can  be  seen  radiating  from  the  rete  testis.  The 
tunica  albuginea  is  thickened;  the  tunica  vaginalis  contains  a 
small  quantity  of  fluid  and  is  thickened  in  patches  or  throughout. 
Fibrous  adhesions  form  between  the  walls,  and  occasionally  com- 
plete obliteration  of  the  cavity  occurs. 

778 


5^a 


/ 


Gumma  of  testicle  ulcerating  on  surface  of  scrotum.     (P.   779. 


Plate  43. 


CHAP.   LXIV] 


SYPHILITIC   ORCHITIS 


779 


The  epididymis  and  vas  deferens  are  unaffected. 

Gummata  may  exist  separately,  or  they  may  be  found  in  a 
testicle  the  seat  of  diffuse  syphilitic  orchitis.  There  may  be  a 
single  gumma  or  several  gummata,  varying  in  size  from  a  pea  to 
a  chestnut.  (Fig.  244.)  They  are  yellowish-white,  elastic,  and 
soft  in  the  centre.  Around  the  central  caseous  portion  there  is 
a  fibrous  capsule  of  varying  thickness,  and  outside  this  a  gre5rish 
cellular  ring.  The  changes  in  the  tunica  albuginea  and  tunica 
vaginalis  are  similar  to  those  found  in  diffuse  syphilitic  orchitis. 


Fig.  244. — Gumma  of  testicle  and  hydrocele. 

In  the  early  stage  the  condition  may  disappear  under  treatment. 
Atrophy  of  the  testis  frequently  follows. 

A  gumma  may  soften,  form  adhesions  with  the  skin  of  the 
scrotum,  and  break  through  on  the  surface.  A  deep,  crater-like 
ulcer  with  greyish-white  base  is  now  formed  (Plate  43),  or  a 
fungating  mass  consisting  of  granulation  tissue  and  necrosing 
testicular  tissue  may  protrude  (hernia  testis). 

In  congenital  syphilis  diffuse  orchitis  may  occur. 

Symptoms. — The  testicle  becomes  slowl}^  and  painlessly 
enlarged.  Rarely  the  onset  is  sudden  and  the  enlargement  rapid, 
and  there  are  pain  and  tenderness. 

One  testicle  is  affected,  and  the  organ  becomes  greatly  enlarged. 
A  small  hydrocele  is  frequently  present.     The  testicle  is  oval,  and 


780  THE   TESTICLE  [chap,  lxiv 

may  show  one  or  more  nodules,  which  are  firm  or  hard.  Testicular 
sensation  is  absent. 

Diagnosis. — There  is  rarely  any  difficulty  in  distinguishing 
tuberculosis.  This  afiects  the  epididymis  and  not  the  body  of 
the  testicle  until  a  very  late  stage  ;  it  is  rarely  accompanied  by 
hydrocele,  and  there  are  tenderness  and  testicular  sensation.  The 
formation  of  sinuses  which  heal  and  reopen  is  characteristic  of 
tuberculosis.  Tuberculous  nodules  may  be  found  along  the  vas 
deferens  or  elsewhere  in  the  genital  organs.  From  new  growth 
of  the  testicle  the  diagnosis  is  made  by  the  history  of  S3rphilis  and 
the  efiect  of  antisyphilitic  treatment.  A  new  growth  is  more 
nodular  and  less  uniform  in  consistence,  being  soft  in  some  parts 
and  hard  in  others.     The  cord  is  frequently  thickened. 

Treatment. — Rapid  improvement  usually  takes  place  under 
antisyphilitic  treatment.  Iodides  are  given  alone  or  combined 
with  mercury,  and  the  testicle  may  be  covered  with  Scott's  dress- 
ing. Should  any  doubt  remain  in  regard  to  the  diagnosis  between 
syphilitic  and  malignant  disease,  the  testicle,  which  is  already 
functionless,  should  be  removed. 


CHAPTER  LXV 

TUBERCULOSIS  OF  THE  EPIDIDYMIS  AND 
TESTICLE 

The  epididymis  is  first  attacked,  the  body  of  the  testicle  becoming 
involved  later.  This  forms  the  primary  focus  in  the  genital  organs 
in  a  large  proportion  of  cases  of  genital  tuberculosis  {see  p.  685). 
In  children  the  body  of  the  testicle  is  more  frequently  affected. 

Etiology. — The  disease  occurs  between  the  ages  of  13  and  30, 
but  may  develop  in  adult  life,  and  even  in  old  age.  Of  100  cases 
of  genital  tuberculosis  under  my  care  the  genital  system  was 
afiected  alone  in  50,  the  genital  and  urinary  systems  in  37,  the 
genital  system  with  tuberculosis  elsewhere  (lymph-glands,  joints, 
vertebrse,  lungs)  in  13.  Of  the  100  cases  the  epididymis  was 
affected  in  72,  and  in  26  it  was  the  only  organ  affected  ;  in  16  it 
was  affected  with  the  prostate,  in  14  with  the  seminal  vesicle, 
and  in  16  with  the  prostate  and  seminal  vesicle.  The  tuberculous 
epididymitis  where  this  organ  only  was  affected  was  unilateral 
in  17  and  bilateral  in  9  ;  where  other  parts  of  the  genital  system 
(seminal  vesicle,  prostate)  were  affected  the  disease  was  bilateral 
in  15  and  miilateral  in  31. 

There  is  usually  a  history  of  tuberculosis  in  the  family  ;  and 
frequently  there  are  obsolete  and  occasionally  active  tuberculous 
foci  in  other  parts  of  the  body. 

A  history  of  injury  is  commonly  obtained,  and  experimental 
work  on  animals  has  shown  that  injury  is  an  important  factor 
in  the  etiology  of  tuberculosis  of  the  testicle. 

Previous  infection  with  the  gonococcus  is  believed  to  pre- 
dispose to  the  development  of  tuberculous  epididymitis.  In  the 
majority  of  cases  there  has  been  no  gonorrhoeal  epididymitis,  and 
in  many  no  gonorrhoeal  infection  of  the  urethra.  Many  cases, 
where  the  onset  is  very  acute  and  the  diagnosis  of  preceding 
gonorrhoeal  epididymitis  is  made,  are  probably  instances  of  acute 
tuberculous  epididymitis,  the  disease  becoming  chronic  after  some 
weeks. 

Pathology.- — The  bacilli  may  be  conveyed  by  the  blood  stream 
and  deposited  in  the  capillaries  of  the  epididymis,  or  invasion  of 

781 


782  THE   TESTICLE  [chap. 

the  epididymis  by  way  of  the  vas  deferens  may  occur  where  the 
disease  is  secondary  to  tuberculous  prostatitis. 

Macfarlane  Walker  has  adduced  evidence  in  support  of  the 
view  that  the  tuberculous  infection  commences  in  the  prostate 
and  spreads  along  the  lymphatics  of  the  cord  to  the  lower  end  of 
the  epididymis.  The  distribution  of  the  tuberculous  tissues,  he 
holds,  suggests  two  opposing  waves  of  infection — a  primary  one, 
travelling  from  the  prostate  along  the  lymphatics  to  the  epididy- 
mis ;  and  a  secondary  one,  in  the  lumen  of  the  vas  and  passing  from 
the  epididymis  towards  the  prostate,  due  to  the  flow  of  infected 
secretions  from  the  diseased  epididymis. 

The  tuberculous  process  does  not  differ  from  that  found  else- 
where. Giant-cell  systems  are  abundant,  and  bacilli  may  be 
found.  At  first  there  is  usually  a  single  nodule,  which  spreads 
until  the  whole  epididymis  is  involved,  the  organ  containing  a 
number  of  caseous  nodules  or  a  single  irregular  caseous  mass. 
Either  the  head  or  the  tail  of  the  epididymis  may  be  affected,  the 
latter  rather  more  frequently  than  the  former.  The  tuberculous 
nodule  may  soften  and  break  down  ;  the  skin  becomes  adherent 
and  thinned,  and  the  abscess  ruptures  on  the  surface,  forming 
a  fistulous  tract,  or  more  rarely  a  deep,  crater-like  ulcer.  In 
the  late  stage  the  testicle  becomes  involved  and  is  the  seat  of 
caseous  masses,  especially  near  the  rete  testis,  and  there  are  scat- 
tered tubercles  throughout  the  substance  of  the  gland  (Plate  44). 
If  suppuration  occurs  and  the  abscess  ruptures  on  the  surface  a 
mass  of  granulation  tissue  and  degenerating  testicular:  substance 
may  protrude  and  form  a  hernia  testis. 

Symptoms. — There  are  two  clinical  varieties  of  tuberculous 
epididymitis — (1)  an  acute,  (2)  a  chronic. 

1.  Acute  tuberculous  epididymitis  occurs  comparatively 
frequently.  It  is  not  uncommonly  mistaken  for  gonorrhoeal  epi- 
didymitis, in  spite  of  the  patient's  protests  that  no  risk  of  infec- 
tion has  been  incurred.  There  is  sudden  acute  pain  in  the  testicle, 
the  epididymis  is  tender  and  rapidly  swells,  and  in  two  or  at  most 
three  days  has  reached  a  large  size.  There  is  often  a  purulent 
urethral  discharge,  due  in  most  cases  to  tuberculous  prostatitis. 
Tubercle  bacilli  may  be  found  in  this  discharge.  After  some  weeks 
softening  appears  at  one  part  of  the  epididymis  and  an  abscess 
forms  and  bursts.  After  this  the  epididymitis  assumes  a  more 
chronic  form. 

The  points  which  distinguish  acute  tuberculous  epididymitis 
from  gonorrhoeal  epididymitis  where  there  is  a  possibility  of  recent 
or  old  gonococcal  infection  are  :  (1)  The  pain  and  tenderness  are 
usually  less  acute  ;   (2)  there  is  abscess  formation  ;   (3)  tuberculous 


Tuberculosis   of  epididymis  with    tuberculous  abscess  under 
skin  of  scrotum  and  miliary   tubercle  of  testicle.     (P.   782.) 


Plate  44. 


Lxv]  TUBERCULOUS   EPIDIDYMITIS  783 

lesions  are  present  in  the  prostate,  seminal  vesicles,  the  second 
epididymis,  or  urinary  organs  ;  (4)  the  discharge  is  more  watery 
and  the  urethral  symptoms  are  slight  or  absent ;  (5)  tubercle 
bacilli  may  be  found  in  the  discharge,  and  gonococci  are  absent. 

2.  Chronic  tuberculous  epididymitis. — A  nodule  develops  in- 
sidiously in  the  tail  or  in  the  head  of  the  epididymis.  The  attention 
of  the  patient  may  be  attracted  to  it  by  some  slight  injury,  when 
a  nodule  the  size  of  a  pea  or  bean  is  discovered ;  this  is  tender, 
hard,  and  either  irregular  in  shape  or  smooth.  Later  the  whole 
of  the  epididymis  becomes  involved,  and  forms  a  hard,  irregular, 
craggy  mass  lying  vertically  on  the  back  of  the  testicle. 

Hydrocele  is  usually  absent,  but  a  small  quantity  of  clear  or 
flocculent  fluid  is  present  in  the  tunica  vaginalis  in  about  one- 
third  of  the  cases.  Adhesions  between  the  walls  frequently  form. 
The  tubercle  bacillus  is  rarely  found  in  the  fluid.  The  vas  deferens 
is  frequently  invaded,  and  may  show  a  series  of  small  nodular 
thickenings  or  a  uniform  thickening  ;  or  there  may  be  nothing 
clinically  to  show  that  the  duct  is  invaded,  but  microscopic 
sections  reveal  that  it  is  tuberculous.  There  are  tuberculous 
nodules  in  the  seminal  vesicles  in  19-4  per  cent,  of  cases,  and  in 
the  prostate  in  22-2  per  cent. 

Urinary  tuberculosis  is  a  frequent  complication  ;  it  occurred  in 
37  per  cent,  of  my  cases.  It  is  not  unusual  to  find  tuberculous 
epididymitis  with  tuberculosis  of  one  kidney,  usually  on  the  same  side. 

The  genital  function  of  the  testicle  is  destroyed  early  in  the 
disease  by  blocking  of  the  vas  deferens.  When  the  disease  is 
bilateral  the  patient  is  sterile. 

Diag^nosis. — The  diagnosis  of  chronic  tuberculous  epididymitis 
is  made  on  the  following  points  :  (1)  The  insidious  onset ;  (2)  the 
absence  of  acute  inflammation ;  (3)  the  hard,  irregular,  well- 
defined  nodules ;  (4)  breaking  down  and  formation  of  sinuses 
which  heal  and  again  break  down ;  (5)  the  presence  of  tuberculous 
nodules  in  the  vas  deferens  and  elsewhere  in  the  genital  organs  ;■ 

(6)  tuberculosis  of  the  urinary  organs  or  elsewhere  in  the  body ; 

(7)  a  tuberculous  family  history.  A  fibrous  nodule  remaining 
after  acute  epididymitis  of  urethral  origin  is  smooth,  tough,  and 
ill  defined,  and  there  are  no  nodules  elsewhere.  In  syphilitic 
affections  the  body  of  the  testis  is  affected  and  the  epididjnms 
remains  free. 

Course  and  progfnosis. — The  tuberculous  nodule  frequently 
breaks  down  and  the  abscess  ruptures,  forming  a  sinus  on  the  skin 
of  the  scrotum.  After  discharging  for  some  months  or  years 
this  may  heal.  Later  there  is  reaccumulation  of  fluid  and  the 
fistula  again  opens,  and  this  may  be  repeated  many  times. 


784  THE   TESTICLE  [chap. 

The  progress  is  usually  very  slow,  and  spontaneous  healing  of 
the  lesion  may  be  observed,  the  craggy  mass  softening  and  shrink- 
ing, and  only  a  tough  thickening  of  the  epididymis  remaining. 
At  some  future  date  the  disease  may  again  become  active,  or  fresh 
tubercle  may  develop  in  the  second  epididymis  or  other  genital 
organs. 

Acute  tuberculous  epididymitis  subsides  after  a  few  weeks 
to  a  chronic  form,  not  infrequently  after  the  rupture  of  an  abscess. 

The  course  of  chronic  tuberculous  epididymitis  is  slow  and 
usually  extends  over  many  years.  The  disease  does  not,  however, 
remain  localized  to  one  epididymis.  In  a  few  months,  or  after  a 
year  or  more,  a  tuberculous  nodule  appears  in  the  second  epi- 
didymis. At  this  time  nodules  will  very  frequently  be  detected 
in  the  prostate,  and  in  one  or  both  seminal  vesicles. 

Tuberculous  disease  of  the  kidney,  either  on  the  same  side  as 
the  affected  epididymis  or  on  the  opposite  side,  may  supervene, 
or  the  bladder  may  become  infected  from  the  prostate  or  seminal 
vesicles.  In  some  cases  the  genital  tuberculosis  becomes  quiescent, 
and  occasionally  it  completely  disappears,  so  that  no  trace  of  it 
can  be  discovered  in  the  epididymis,  a  healed  fibrous  track  lead- 
ing to  a  depressed  scar  being  the  only  evidence  of  bygone  disease. 

In  other  cases,  after  remaining  quiescent  for  many  years  the 
tuberculous  process  awakens  to  renewed  activity  in  the  epididy- 
mis, or  fresh  tuberculous  deposits  appear  in  the  genital  organs  or 
elsewhere. 

Genital  tuberculosis  is  a  comparatively  mild  form  of  tuber- 
culosis, and  is  not  in  itself  dangerous  to  life  :  the  chief  danger  is 
the  involvement  of  the  urinary  organs.  Tuberculous  meningitis 
is  a  rare  sequel. 

Treatment.  Non-operative  treatment  includes  providing 
a  liberal  and  nutritious  diet  and  giving  cod-liver  oil,  iodides 
(syrup  of  the  iodide  of  iron,  1  teaspoonful  thrice  daily  in  milk), 
iron,  and  arsenic. 

The  testicle  should  be  supported  in  a  well-fitting  suspensory 
padded  with  cotton- wool,  and  all  possible  causes  of  injury  such 
as  bicycle-  and  horse-riding  should  be  interdicted.  Local  applica- 
tions such  as  Scott's  dressing  are  worthless.  Residence  in  a  warm 
climate  is  beneficial. 

Tuberculin  treatment  can  claim  many  successes.  In  a  large 
number  of  cases  the  tuberculous  nodule  diminishes  in  size,  becomes 
less  hard  and  irregular,  and  eventually  soft,  and  difficult  or 
impossible  to  detect.  This  improvement  takes  place  rapidly 
in  some  cases,  but  more  usually  slowly,  and  the  treatment  lasts 
a  year  or  longer.     In  some  cases,  especially  the  more  acute,  an 


Lxv]  TUBERCULOUS   EPIDIDYMITIS  785 

abscess  forms,  and  after  this  is  opened  liealinr,'  takes  place.  The 
dosage  commences  at  inuoo  nig.  (T.R.)  and  rises  slowly  to  ,o',(y 
or  even  ^^o  mg. 

Operative  treatment  consists  in — 

1.  Conservative  measures. 

2.  Epididymectomv. 

3.  Castration. 

1.  Conservative  measures  consist  in  opening  and  scraping 
abscesses  as  they  appear,  but  no  attempt  is  made  completely  to 
eradicate  tlie  disease.  The  wall  of  the  cavity  is  rubbed  with 
iodine  solution  or  dusted  with  iodoform  and  Hghtly  packed  with 
gauze.  These  measures  are  used  coincidentally  with  treatment 
by  tuberculin  and  other  general  treatment. 

2.  E'pididymectomy  consists  in  removal  of  the  epididymis  and 
preserving  the  testicle.  An  incision  2|  in.  long  is  made  from 
the  external  abdominal  ring  downwards  over  the  testicle.  If  the 
organ  is  adherent  to  the  skin  of  the  scrotum,  or  if  a  sinus  exists, 
this  part  of  the  scrotum  is  excised.  The  testicle  is  delivered  from 
the  wound  and  turned  inwards,  and  the  epididymis  exposed  by 
incision  of  the  coverings.  Care  is  taken  to  interfere  as  little  as 
possible  with  the  blood-vessels,  and  the  arterial  supply  of  the 
testis  which  enters  the  organ  at  the  upper  end  of  the  epididymis 
is  carefully  preserved.  The  epididymis  is  freed  by  blunt  dis- 
section and  detached  from  the  testis,  commencing  at  the  lower  end. 
The  attachment  of  the  globus  major  to  the  testis  is  cut  across, 
the  blood-vessels  being  avoided,  and  the  epididymis  is  detached. 
The  vas  deferens  is  now  isolated  as  far  as  the  internal  abdominal 
ring,  the  inguinal  canal  being  opened  up,  if  necessary,  and  liga- 
tured. After  all  bleeding-points  have  been  tied  and  the  inguinal 
canal  repaired,  the  wound  is  closed.  The  advantage  of  this  opera- 
tion is  that  the  body  of  the  testicle  is  not  removed  and  its  internal 
secretion  is  preserved.  When  one  testicle  only  is  affected  this 
is  not  of  such  great  importance  as  when  the  disease  is  bilateral, 
but  the  possibihty  of  future  infection  of  the  second  epididymis 
when  the  disease  is  unilateral  must  be  considered.  The  operation 
of  epididymectomy  will  allow  of  castration  of  the  second  testicle 
should  this  be  necessary,  and  the  patient  will  still  retain  the  internal 
secretion  of  the  first  testicle.  The  objection  to  the  operation  is 
that  tuberculosis  may  already  have  spread  to  the  body  of  the 
testicle  and  the  operation  is  not  radical. 

In    the    common    form    of    chronic    tuberculous    epididymitis 
the  disease  is  confined  to  the  epididymis,  and  the  body  of    the 
testicle  is  only  affected  at  a  late  stage.     In  subacute  and  acute 
cases  the  body  of  the  testicle  is  more  likely  to  be  affected. 
2-s 


786  THE   TESTICLE  [chap. 

When  an  isolated  tuberculous  nodule  exists,  or  when  the  whole 
epididymis  is  converted  into  a  very  hard,  well-defined  mass  and 
the  testicle  is  soft,  it  is  unlikely  that  the  body  of  the  testicle  is 
invaded ;  but  when  the  limitation  of  the  disease  is  indefinite  and 
its  attachment  to  the  testicle  broad,  spread  to  that  organ  may 
be  surmised.  It  is  frequently  impossible,  however,  to  make  an 
accurate  diagnosis  as  to  the  involvement  of  the  testis.  Scraping 
of  the  tuberculous  testis  after  epididymectomy,  or  excision  of  por- 
tions of  the  body  of  the  organ,  is  unsatisfactory,  and  orchidectomy 
is  the  only  radical  form  of  treatment  when  the  disease  has  spread 
into  the  testis. 

Permission  for  this  operation,  should  it  become  necessary,  must 
be  obtained  before  commencing  the  epididymectomy.  Necrosis 
of  the  testis  from  interference  with  its  blood  supply  has  been 
recorded. 

The  operation  of  epididymectomy  is  suitable  for  early  tuber- 
culous disease  limited  to  the  epididymis.  It  is  contra-indicated 
in  cases  in  which  the  body  of  the  testicle  is  involved,  or  where 
there  is  advanced  disease  of  the  prostate  and  seminal  vesicles  or 
of  the  urinary  organs. 

3.  Castration. — Removal  of  the  testicle  may  be  commenced 
by  isolating  and  tying  the  cord,  or  by  dissecting  out  the  testicle 
and  then  tying  and  severing  the  cord.  Of  the  two  methods  the 
former  is  the  better.  The  penis  is  fixed  to  the  opposite  groin 
with  a  stitch ;  an  incision  is  made  about  2  in.  long  with  its  centre 
a  little  below  the  external  abdominal  ring,  and  the  ring  defined. 
The  external  oblique  aponeurosis  is  slit  up  as  far  as  the  internal 
ring,  and  the  cord  isolated  and  transfixed  with  strong  catgut. 
The  two  halves  are  carefully  tied,  one  of  the  ligatures  being  finally 
passed  romid  the  whole  cord  and  tied.  The  cord  is  cut  across 
i  in.  below  the  ligature  ;  the  lower  end  of  it  is  stripped  down- 
wards and  the  testicle  dislocated  from  the  scrotum  and  removed, 
together  with  any  portion  of  the  scrotum  which  is  adherent.  The 
inguinal  canal  is  now  closed  as  in  the  radical  operation  for  hernia, 
all  bleeding-points  being  carefully  secured  and  a  small  drain 
placed  in  the  lowest  part  of  the  scrotum  for  two  days  in  case  of 
oozing.  Should  the  vas  deferens  be  diseased  at  the  internal  ring 
it  may  be  dissected  up  for  some  distance  to  the  side  of  the  bladder 
before  tying  the  cord,  and  then  tied  and  cut. 

Von  Biingner  has  introduced  a  method  of  forcible  avulsion  of 
the  vas  deferens  by  which  the  duct  is  pulled  upon  until  it  gives 
way  at  some  point  in  the  pelvis.  Four-fifths  of  the  length  of  the 
vas  can  thus  be  removed,  and  the  deeper  part  is  frequently  found 
diseased,  although  no  evidence  of  this  could  previously  be  obtained 


Lxvj  TUBERCULOUS   EPIDIDYMITIS  787 

by  the  finger.  Serious  haemorrhage  in  the  depth  of  the  pelvis 
has  followed  this  operation  in  a  number  of  cases,  and  it  is  not 
recommended. 

More  extensive  operations  have  been  practised  by  Villeneuve, 
Young,  Pauchet,  Marion,  and  others  -with  the  object  of  removing 
the  whole  tuberculous  genital  system. 

Pauchet  first  lays  open  the  inguinal  canal  and  isolates  the 
vas  deferens  as  far  as  the  neighbourhood  of  the  seminal  vesicle, 
cutting  it  with  the  cautery  between  two  ligatures.  The  inguinal 
canal  is  now  closed  and  the  skin  wound  prolonged  into  the  scrotum. 
If  the  epididymis  alone  is  tuberculous  the  testicle  is  preserved, 
otherwise  castration  is  performed.  A  transverse  prerectal  perineal 
incision  is  made,  the  prostate  and  seminal  vesicles  are  exposed, 
and  both  removed  if  they  are  tuberculous.  Young  removes  the 
vesicles  and  a  portion  of  the  prostate  by  a  suprapubic  T-shaped 
incision  and  separation  of  the  peritoneum  from  the  bladder.  Such 
operations  are  only  called  for  in  exceptional  cases  of  advanced 
genital  tuberculosis. 

Bilateral  castration  has  a  very  deleterious  effect,  especially  on 
older  patients.  They  lose  interest  in  their  affairs,  become  indolent, 
irritable,  and  morose,  and  in  some  cases  demented  and  maniacal, 
and  some  have  committed  suicide.  It  is  possible  also,  judging 
from  experiments  on  dogs,  that  the  loss  of  the  internal  secretion 
may  render  the  patients  less  resistant  to  the  tubercle  bacillus. 

Choice  of  treatment  and  results. — If  tuberculous  disease 
is  apparently  limited  to  one  epididymis,  and  epididymectomy  or 
castration  is  performed,  no  further  development  of  the  disease 
may  take  place.  In  a  considerable  number  of  cases,  however, 
the  second  epididymis  becomes  tuberculous,  or  nodules  develop 
in  the  prostate  or  seminal  vesicles,  either  soon  after  the  operation 
or  after  a  period  of  some  years. 

When  one  epididymis  is  affected  together  with  the  prostate 
and  seminal  vesicles,  removal  of  the  epididymis  or  castration  is 
followed  by  marked  improvement,  and  frequently  by  disappearance 
of  the  prostatic  or  vesicular  disease. 

Removal  of  both  testicles  in  bilateral  disease  does  not  prevent 
the  development  at  a  later  date  of  renal  tuberculosis,  or  neces- 
sarily cause  arrest  in  the  progress  of  prostatic  or  vesicular  disease, 
although  it  has  an  undoubted  influence  in  causing  the  arrest  of 
disease  which  is  present,  and  preventing  the  appearance  of  fresh 
infection. 

Of  45  cases  of  castration  collected  by  Konig  the  prostate  or 
vesicles  were  involved  in  31,  one  testicle  being  affected  in  17  and 
both  in  14.     Of  the  17  cases  in  which  one  testicle  was  involved 


788  THE   TESTICLE  [chap,  lxv 

14  were  followed  for  over  two  years,  and  there  were  10  complete 
cures,  1  case  of  improvement,  and  1  death.  Of  the  14  bilateral 
cases  9  were  cured,  2  improyed,  and  2  died. 

Of  26  cases  of  epididymectomy  recorded  by  Dimitresco  13  were 
traced  for  from  one  to  nine  years.  There  were  11  complete  cures 
— 7  unilateral,  4  bilateral. 

Tuberculin  treatment  gives  good  results  in  chronic  tuberculous 
epididymitis,  and  may  be  used  either  alone  or  for  the  treatment 
of  prostatic  or  vesicular  disease  after  removal  of  the  tuberculous 
epididymis. 

My  practice  is  to  treat  chronic  tuberculous  epididymitis  with 
tuberculin  and  to  limit  operative  procedures  to  opening  and  scraping 
abscesses  when  they  arise.  If  the  disease  appears  to  be  spreading 
is  spite  of  the  tuberculin  treatment  epididymectomy  is  performed, 
and  if  it  is  already  very  extensive  or  has  involved  the  testicle 
this  organ  is  removed.  I  have  not  found  it  necessary  to  perform 
extensive  operations  for  the  removal  of  the  pehdc  portion  of  the 
vas  deferens. 

LITERATURE 

Baudet,  Bev.  de  Chir.,  1909,  p.  952. 

Bolton,  Journ.  of  Cutan.  and  Gen.-Urin.  Dis.,  Dec,  1899. 

von  Biingner,  Gentralbl.  f.  Chir.,  Nov.  18,  1893. 

Carless,  Pract.,  July,  1901. 

Cheyne,  Watson,  Brit.  Med.  Journ.,  Dec.  30,  1899. 

Dimitresco,  These  de  Paris,  1897. 

Keyes,  Ann.  of  Surg.,  June,  1907. 

Konig,  Debits.  Zeits.  f.  Chir.,  1898,  vol.  xlvii. 

Longuet,  Bev.  de  Chir.,  Jan.,  1900. 

Marion,  Arch.  Gen.  de  Chir.,  1910,  p.  151. 

Moullin,  Brit.  Med.  Journ.,  Jan.  13,  1900. 

Paucliet,  Rev.  de  Chir.,  1909,  p.  195. 

Poissonnier,  Gaz.  des  Hop.,  March  16,  1907. 

Southam,  Brit.  Med.  Journ.,  April  21,  1900. 

Tylinski,  Deuts.  Zeits.  f.  Chir.,  1911,  Hefte  4-6. 

Walker,  Macfarlane,  Lancet,  1913,  i.  435. 

Young,  Ann.  of  Surg.,  1901,  ii.  601. 


CHAPTER  LXVI 
NEW  GROWTHS  OF  THE  TESTICLE 

New  growths  of  the  testicle  are  comparatively  rare.  Howard 
collected  65  cases  in  110,000  male  patients  (0-06  per  cent.)  admitted 
to  the  London  Hospital  in  twenty  years. 

Etiology. — The  etiology  of  testicular  new  growths  is  unknown, 
but  certain  facts  related  to  their  development  are  recognized. 
There  is  a  definite  history  of  recent  injury  in  about  one-quarter 
of  cases.  Venereal  disease  has  no  relation  to  the  occurrence  of 
new  growth. 

The  average  age  is  a  little  over  30  years.  The  testicle  has 
been  the  seat  of  new  growth  in  an  infant  and  in  patients  over 
80  years.  The  "  fibrocystic  "  growth  occurs  between  the  ages  of 
25  and  35.  Each  testicle  is  about  equally  affected,  and  with  the 
exception  of  a  single  case  of  lymphadenoma  (Monod  and  Terillon) 
the  condition  is  invariably  unilateral. 

It  is  generally  held  that  mahgnant  disease  occurs  frequently 
in  an  imperfectly  descended  testicle.  The  London  Hospital 
statistics  support  this  view.  Of  57  cases  9  occurred  in  retained 
testis  (15-7  per  cent.).  The  retained  testis  may  lie  within  the 
abdomen,  in  the  inguinal  canal,  or  just  outside  the  external 
ring. 

Pathology. — All  new  growths  of  the  testicle  must  be  regarded 
as  malignant.  Tumours  described  as  fibroma,  adenoma,  chon- 
droma, myxoma,  lipoma,  and  myoma  are  either  the  predominating 
constituents  of  a  mixed  growth  or  are  so  rare  as  to  be  of  no  clinical 
interest.  An  embryonal  tumour  may  remain  stationary  for  many 
years,  but  eventually  takes  on  rapid  growth. 

The  following  arrangement  of  new  growths  is  based  upon  the 
classification  suggested  by  Nicholson  : — 
r  Fibro-cystic. 
Embryoma..-    Cystic  (dermoid). 

[  Chorion-epithelioma. 
/  ,  .     J  Alveolar. 

Carcinoma  .  .  |  ^  \  Non-alveolar. 

(  Scirrhus. 

789 


790  THE   TESTICLE  [chap. 

a  i  Round-celled  (lymphadenoma). 

barcoma  .  .  .  .  <  t.^  \  j     r  i 

\  Myxo-sarcoma. 

T-,    ,  jT    T         f Lymphendothelioma. 
Endothelioma  i  •„-  j  ^i,  r 

(  Haemendotnelioma. 

An  emhryoma  contains  elements  derived  from  the  three  primary 

layers,  epiblast,  mesoblast,  and  hypoblast.     When  two  or  all  of 

these  layers  develop  a  mixed  tumour  results.    (Fig.  245.)    When  one 

element  greatly  predominates  a  tumour  of  corresponding  struc- 


• :    ,  /^  ''•  "'"''■  '/'\  ■„'<>,  V r°>C> ,  ';  '"'  ■' /P?^^.'*'^^> / 


Fig.  245. — Section  of  portion  of  a  mixed  tumour  of  testicle. 

ture  results :  a  columnar-celled  carcinoma  develops  from  the 
hypoblastic  layer,  a  sarcoma  from  the  mesoblast;  and  when  the 
epiblast  alone  develops,  a  growth  formed  of  the  epiblastic  struc- 
tures mentioned  below  is  produced,  or  a  chorion-epithelioma  repre- 
senting an  earlier  stage  of  development  of  epiblast  may  be  formed. 
When  one  layer  is  not  found,  usually  the  epiblast,  it  has  either 
been  suppressed  or  overlooked. 

The  epiblastic  structures  found  are  stratified  epithelium  lining 
cysts,  or  solid  epithelial  rods,  or  the  epithelium  may  be  of  the 
transitional  type.  Teeth,  grey  matter,  rudimentary  retina,  and 
portions  of  a  spinal  cord  have  also  been  found. 


ixvij  TESTICULAR  NEW  GROWTHS  791 

The  mesoblastic  elements  may  be  connective  tissue,  embryonic 
or  fibrous,  myxomatous  areas,  hyaline  cartilage,  bone,  unstriped 
muscle,  lymphoid  follicles. 

HypolDlastic  structures  comprise  columnar  epithelium  containing 
goblet  cells,  ciliated  epithelium,  alveoli  resembling  tubular  glands. 

The  solid  embryoma  may  show  cystic  spaces  on  section,  but 
the  whole  tumour  may  consist  of  cysts  of  varying  size  separated 
by  fibrous  tissue,  the  variety  known  as  "  fibro-cystic  growth  "  of 
the  testicle. 

Cystic  embryomas  or  dermoids  are  very  rare.  They  show  a 
thick  wall  lined  partly  or  completely  with  epithelium,  and  contain- 
ing hair,  sebaceous  glands,  teeth,  nervous  elements,  etc.  A  pro- 
cess composed  of  elements  from  the  three  germinal  layers  with 
a  large  proportion  of  nervous  tissue,  and  said  to  correspond  to 
the  anterior  end  of  an  embryo,  projects  into  the  interior.  Bar- 
rington  has  described  what  appears  to  be  a  unique  case  in  which 
a  dermoid  was  combined  with  an  alveolar  carcinoma. 

The  embryomas  all  originate  within  the  testicle.  The  tunica 
albuginea  can  be  seen,  and  frequently  a  thin  layer  of  testicular 
substance  is  spread  over  the  tumour  (Plate  45). 

Of  the  carcinomas,  Nicholson  looks  upon  the  columnar-celled 
variety  as  representing  the  preponderance  in  development  of  the 
hypoblastic  layer  in  a  teratoma.  He  recognizes,  however,  an 
alveolar  carcinoma  formed  of  groups  of  epithelial  cells  surrounded 
by  a  small  amount  of  fibrous  tissue  carrying  blood-vessels,  and 
a  non-alveolar  which  consists  of  cells  embedded  in  an  open  mesh- 
work  of  fibrous  trabeculse. 

Sarcoma  may  be  lympho-sarcoma  or  myxo-sarcoma.  These 
tumours  grow  very  rapidly,  and  are  stated  to  affect  both  testicles 
and  quickly  form  metastases,  especially  in  the  skin. 

The  endotheliomas  resemble  those  met  with  elsewhere. 
The  comparative  frequency  of  the  different  varieties  is  disputed, 
and  until  a  more  uniform  view  of  the  pathology  is  held  no  reliable 
information  will  be  obtained  in  regard  to  this  point. 

The  origin  of  the  different  varieties  also  is  much  disputed. 
Carcinoma  is  said  to  develop  from  the  epithelium  of  the  seminal 
tubules,  and  sarcoma  from  the  stroma. 

The  embryomas  have  been  said  to  arise  in  the  follo^^ing  ways  : — 
Cell  metaplasia. 
FcEtal  inclusion. 
Partial  hermaphroditism. 
Fertilization  of  a  polar  body. 
An  isolated  blastoma. 
Eeimiants  of  the  Wolffian  body  or  Miiller's  duct. 


792  THE   TESTICLE  [chap. 

Shattock  has  advanced  the  following  theory  for  the  origin  of 
both  ovarian  and  testicular  embryomas.  The  ovarian  (or  testi- 
cular) embryoma  results  from  the  fertilization  of  one  of  the  germ 
cells  of  the  genital  ridge  by  a  stray  spermatozoon.  It  is  well 
known  that  several  spermatozoa  may  penetrate  the  investing 
membrane  of  the  ovum,  and  Shattock  suggests  that  a  spermatozoon 
other  than  that  which  fertilizes  the  ovum  may  remain  alive  and 
become  buried  in  the  cells  of  the  segmenting  fertilized  ovum 
(morula)  and  eventually  fertilize  one  of  the  primordial  ova  or 
germ  cells  of  the  fcetus,  which  are  developed  very  early.  The 
longevity  of  spermatozoa  under  favourable  conditions  is  not  known, 
but  there  is  reason  to  suppose  that  it  may  be  six  weeks  in  fowls. 

New  growths  taking  origin  in  the  epididymis  are  very  rare. 
Rowlands  and  Nicholson  describe  a  case  of  squamous-celled  car- 
cinoma of  the  epididymis. 

Spread  to  lymph-glands  takes  place  early.  Those  first  affected 
are  the  lumbar  glands,  which  lie  along  the  inferior  vena  cava  and 
aorta  and  extend  from  the  bifurcation  of  the  aorta  as  high  as 
the  renal  arteries.  The  inguinal  glands  are  sometimes  affected 
without  any  involvement  of  the  scrotal  tissues.  Bland-Sutton 
mentions  a  case  in  which  a  fibro-cystic  growth  formed  a  metas- 
tasis by  way  of  the  thoracic  duct  in  a  gland  in  the  neck. 

Symptoms. — ^In  the  early  stage  there  is  neither  pain  nor  dis- 
comfort, but  as  the  growth  increases  in  size  the  patient  complains 
of  the  weight  of  the  testicle,  and  there  is  dragging  pain  along  the 
cord,  passing  up  to  the  groin ;  there  is  also  pain  in  the  loins. 
Where  secondary  deposits  form  in  glands  there  may  be  shooting 
pain  from  nerve  pressure,  and  oedema  of  the  legs  and  ascites  develop 
from  pressure  upon  the  vena  cava. 

In  the  later  stage  malignant  cachexia  becomes  pronounced. 

Enlargement  of  the  testicle  is  confined  to  the  body  of  the 
organ  and  does  not  affect  the  epididymis.  The  testicle  is  uniformly 
enlarged,  forms  a  smooth  oval  tumour,  and  retains  its  normal 
shape  ;  it  may  eventually  reach  the  size  of  a  cocoa-nut.  As  the 
tumour  increases  in  size  one  or  more  rounded  nodular  swellings 
appear  at  the  surface.  These  bosses  are  softer  than  the  rest  of 
the  tumour,  and  are  due  to  necrosis  of  the  growth,  or  to  a  haemor- 
rhage into  its  substance.  The  testicle  is  heavy  when  supported 
by  the  hand.  It  is  usually  very  hard,  and  is  insensitive.  In 
rapidly  growing  neoplasms  with  extensive  degeneration  the  tumour 
may  be  soft,  and  even  give  an  impression  of  fluctuation,  which 
has  led  to  puncture  of  the  supposed  fluid  swelling.  Testicular 
sensation  is  lost  when  the  growth  has  destroyed  the  testicular 
tissue,  but  it  is  present  at  some  part  of  the  swelling  in  the  early 


Solid  embryoma  of  testicle ;  operation  specimen.  A  thin 
layer  of  testicular  tissue  can  be  seen  surrounding  the 
growth.     (P.  791.) 


Plate  45. 


Lxvi]  TESTICULAR   NEW   GROWTHS  793 

stage  of  development.  The  epididymis  can  be  felt  unaltered  in 
the  early  stage  ;  as  the  growth  enlarges,  it  becomes  flattened 
and  stretched  over  the  surface,  and  cannot  be  detected  on 
palpation.  The  globus  major  may  be  felt  at  the  upper  part  of 
the  swelling. 

Fluid  is  not  infrequently  present  in  the  tunica  vaginalis,  but 
is  moderate  in  quantity.  It  may  occupy  the  whole  sac  or  be 
confined  to  the  upper  or  lower  pole,  the  rest  of  the  sac  being 
obliterated. 

The  cord  is  usually  unchanged,  but  there  may  be  thickening 
due  to  hypertrophy  of  the  cremaster  muscle  and  engorgement  of 
the  veins.  The  veins  of  the  scrotum  may  be  engorged,  and  in  the 
late  stage  the  growth  becomes  adherent  to  the  skin  of  the  scrotum 
and  eventually  f ungates.  Enlargement  of  the  lumbar  glands 
forms  a  deep-seated  mass  lying  alongside  the  spine  at  the  level 
of  the  umbihcus.     The  inguinal  glands  may  also  be  enlarged. 

When  the  gro^\i:h  develops  in  a  retained  testicle  that  side  of 
the  scrotum  is  empty,  and  there  is  a  large,  hard,  adherent  swelhng 
of  irregular  consistence  in  the  inguinal  region.  (Fig.  243,  p.  766.) 
There  is  frequently  oedema  of  the  leg  from  venous  stasis,  and  the 
surface  veins  are  dilated.  In  the  intra-abdominal  retained  testis  a 
deeply  placed  swelling  is  present,  and  ascites  frequently  develops. 

The  average  duration  of  the  disease  when  first  seen  was  from 
six  to  twelve  months,  and  the  longest  time  was  eight  years  in 
Howard's  cases. 

Diagnosis. — Difficulties  in  diagnosis  occur  in  hsematocele, 
hydrocele,  gumma  of  the  testicle,  and  tuberculous  disease. 

In  hsematocele  there  is  usually  a  history  of  recent  injury  and 
of  very  rapid  development,  often  with  acute  pain,  or  a  hydrocele 
may  have  been  tapped  and  rapidly  filled  again. 

In  cases  of  longer  duration,  with  an  indefinite  history  and  no 
evidence  of  injury,  the  diagnosis  may  be  difficult  or  impossible. 
An  exploratory  operation  is  the  only  certain  method  of  diag- 
nosis ;  puncture  with  the  trocar  is  unsatisfactory  and  frequently 
inconclusive. 

In  a  hydrocele  with  a  thick,  hard,  sometimes  calcareous  wall 
the  diagnosis  may  be  difficult.  There  is  usually,  however,  a 
history  of  repeated  tappings,  and  there  is  no  continuous  increase 
in  size.     Exploratory  operation  will  decide  the  diagnosis. 

In  advanced  tuberculous  disease  which  has  spread  from  the 
epididymis  to  the  testicle  a  large  mass  is  formed  and  considerable 
difficulty  may  exist.  Davies  points  out  that  in  some  groTNi:hs  a 
large  part  of  the  tumour  is  broken  down,  so  that  the  whole  anterior 
part  is  soft,   while  the  posterior  part  retains  its  firm,  irregular 


794  THE   TESTICLE  [chap. 

outline,  giving  rise  to  a  condition  resembling  a  tuberculous  epi- 
didymitis with,  a  soft  testicle  in  front. 

The  pain  and  tenderness  of  the  tuberculous  testicle,  the  history 
and  presence  of  tuberculous  nodules  in  other  parts  of  the  genito- 
urinary system  or  elsewhere  in  the  body,  help  the  diagnosis. 
Exploratory  operation  may  occasionally  be  necessary  before  a 
diagnosis  is  finally  made. 

Syphilitic  disease  of  the  testicle  produces  a  hard  nodular  tes- 
ticle ;  the  size  of  the  testicle  is  never  so  great,  the  surface  is  more 
nodular,  the  epididymis  is  distinct  from  the  testicle,  and  there  is 
a  history  of  syphilis  and  a  positive  Wassermann  reaction.  Treat- 
ment with  mercury  and  iodides  shows  rapid  improvement  in 
syphilitic  orchitis. 

Treatment. — Removal  of  the  testicle  by  operation  at  the 
earliest  possible  date  is  the  only  treatment  that  holds  any  promise 
of  cure.  Castration  by  the  usual  method  has  been  the  opera- 
tion practised  until  a  recent  date.  The  results  have,  however, 
been  very  bad,  recurrence  taking  place  in  the  abdominal 
lymphatic  glands  in  the  great  majority  of  cases  soon  after  the 
operation. 

Recently,  G-regoire,  Bland-Sutton,  Roberts,  Davies,  and  others 
have  advocated  a  more  extensive  operation,  foreshadowed  by 
Chevassu  in  his  Thesis  of  1906,  by  which  the  testicle  and  its  lym- 
phatic field  as  far  as  the  first  lymph-glands  are  removed. 

The  lymphatic  system  of  the  testicle  has  been  investigated  by 
Jamieson  and  Dobson.  The  collecting  lymphatic  vessels,  number- 
ing four  to  eight,  leave  the  mediastinum  testis  and  accompany 
the  veins  of  the  cord  lying  in  the  subperitoneal  tissues  on  the  psoas 
to  the  point  where  the  spermatic  vessels  cross  the  ureter.  At  this 
point  they  spread  out  like  a  fan  and,  communicating  laterally, 
empty  into  the  lumbar  lymph-glands.  (Fig.  246.)  The  primary 
lymph-glands  lie  in  front  and  at  the  side  of  the  aorta  and  vena 
cava  below  the  level  of  the  renal  veins.  Each  testicle  has  its  own 
set  of  glands  which  communicate  mth  each  other.  The  actual 
distribution  of  the  glands  varies  much  in  individual  cases.  They 
are  contained  in  an  area  bounded  above  by  the  renal  veins  and 
laterally  by  vertical  lines  a  fingerbreadth  outside  the  aorta  and 
vena  cava,  and  extending  below  to  the  level  of  the  bifurcation 
of  the  aorta.  A  gland  may  be  found  at  the  bifurcation  of  the 
common  iliac  artery. 

The  operation  for  removal  of  this  lymphatic  area  may  be  extra- 
peritoneal or  intraperitoneal,  the  former  being  the  preferable  route. 
An  incision  is  made  over  the  spermatic  cord,  and  extends  upwards 
over  the  external  abdominal  ring  and  inguinal  canal  to  a  point 


LXVl] 


TESTICULAR   NEW  GROWTHS 


795 


^  in.  above  and  internal  to  the  anterior  superior  iliac  spine.  It 
is  then  carried  upwards  to  the  costal  margin  at  the  tip  of  the  10th 
rib  cartilage.  The  testicle  and  cord  are  dissected  out  and  the 
abdominal  muscles  incised  until  the  peritoneum  is  exposed.  The 
cord  is  traced  into  the  abdomen,  the  vas  followed  into  the  pelvis, 
tied,  and  cut  across.  The  fascia  covering  part  of  the  iliacus  and 
psoas  with  its  lymphatics  and  glands  is  dissected  up.  This  strip- 
ping is  carried  along  the  psoas,  being  limited  at  the  outer  border 
of  this  muscle  and  by  the 
line  of  the  common  iliac 
artery  to  the  bifurcation 
of  the  aorta,  the  upper 
limit  being  at  the  level  of 
the  renal  veins.  The  sper- 
matic vessels  are  traced  to 
the  main  vessels  and  liga- 
tured. In  doing  this  the 
ureter  is  separated  from 
the  peritoneum.  The  infe- 
rior mesenteric  artery  is 
carefully  avoided. 

Tliis  operation  has  been 
performed  or  attempted  in 
13  cases  without  as  yet 
giving  very  encouraging 
results. 

Results. — Chevassu  col- 
lected statistics  of  100  cases 
in  which  castration  had 
been  performed,  and  fomid 
19  cures  and  81  deaths. 

Death  took  place  within 
the  first  year  in  47  per  cent,  of  the  fatal  cases.  Of  the  cured 
cases,  13  were  alive  and  well  from  four  to  seven  years,  and  6 
from  seven  to  ten  years  after  the  operation. 

In  the  more  extensive  operation  the  growths  were  incom- 
pletely removed  in  3  cases,  2  are  known  to  have  recurred,  1  was 
well  after  ten  months,  and  1  after  two  years.  The  remaining 
cases  are  too  recent  to  possess  significance.  In  a  case  of  my 
own,  inoperable  glands  were  found  under  the  diaphragm. 

Of  the  London  Hospital  cases  recorded  by  Eussell  Howard, 
only  36  could  be  traced  after  the  operation.  Of  these  27  were 
known  to  have  recurrence  of  the  growth,  and  only  2  of  the  remain- 
ing 8  were  known  to  be  ahve  three  years  after  operation. 


Fig.  246.^ — Lymphatic  glands  con- 
nected with  the  testicle. 

{After  Jainicsoii  and  Dohsoii.) 


796  THE  TESTICLE  [chap,  lxvi 

LITERATURE 

Barrington,  Lancet,  Aug.  12,  1910,  p.  460. 

Bland-Sutton,  Lancet,  Nov.  13,  1909,  p.  1406. 

Calin,  Du  Traitement  Chirurgical  du  Cancer  du  Testicule. 

Chevassu,  Bev.  de  Ghir.,  1910,  p.  628  ;  Tumeurs  du  Testicule,  1906. 

Davies,  Morriston,  Lancet,  Feb.  17,  1912,  p.  418. 

Ewing,  Surg.,  Gyn.,  and  Obst.,  March,  1911,' 

Foulerton,  Lancet,  Dec.  23,  1905,  p.  1827. 

Gr6goire,  Arch.  Oen.  de  Ghir.,  1908,  p.  1. 

Howard,  Russell,  Lancet,  Nov.  18,  1910 ;    Pract.,  1907,  p.  794. 

Nicholson,  Guy's  Hasp.  Eepts.,  1907,  xi.  249. 

Roberts,  Ann.  of^  Surg.,  1902,  p.  539. 

Rowlands  and  Nicholson,  Lancet,  Jan.  30,  1909, 

Shattock,  Lancet,  1908,  i.  479. 


CHAPTER  LXVII 

IMPOTENCE  AND  STERILITY 

In  impotence  there  is  inability  to  perform  the  sexual  act.  Sterilitv 
implies  a  loss  of  procreative  power  and  consists  in  the  absence 
of  living  spermatozoa.  The  two  conditions  do  not  necessarilv 
coexist  in  the  same  individual. 

IMPOTENCE 

Impotence  may  be  (1)  organic,  (2)  psychical,  (3)  atonic. 

1.  Organic  impotence. — Here  an  organic  lesion  interferes  with 
some  part  of  the  mechanism.  The  nervous  apparatus  mav  be 
the  seat  of  disease,  which  affects  the  lumbar  centres  of  the- spinal 
cord  or  the  nervi  erigentes  which  convey  the  impulses.  Thus,  loss 
of  erection  is  an  early  symptom  in  a  large  number  of  cases  of  tabes 
dorsalis,  and  may  be  observed  in  other  syphihtic  affections  of  the 
spinal  cord.  Malformations  of  the  genital  organs  are  frecpentlv 
the  cause  of  impotence.  Absence  or  rudimentary  condition  of  the 
penis  and  extreme  deformities  are  incurable  causes  of  impotence. 
Hypospadias  is  a  frecj[uent  cause,  and  the  impotence  is  due  to 
the  fixed  downward  curve  of  the  penis,  which  becomes  increased 
on  erection,  or  to  the  orifice  of  the  urethra  being  situated  at  the 
peno-scrotal  junction  or  in  the  perineum. 

Scarring  of  the  erectile  tissue  from  injury  or  other  cause,  and 
fibrous  induration  of  the  corpus  cavernosimi  (p.  848),  lead  to  lateral 
or  vertical  deviation  of  the  penis  in  erection,  and  prevent  coitus. 

Phimosis,  tumours,  and  oedema  of  the  penis  interfere  mechanic- 
ally with  connection,  also  such  conditions  as  large  scrotal  hernias, 
hydroceles,  elephantiasis. 

Anorchism  and  complete  destruction  of  the  testicular  tissue 
from  whatever  cause  are  followed  by  impotence. 

The  treatment,  where  treatment  is  possible,  M-ill  be  foimd  in 
the  sections  in  which  the  different  conditions  are  considered. 

2.  Psychical  impotence. — This  is  a  comparatively  frec^uent 
form  of  impotence,  and  is  due  to  nervousness,  fear,  or  other 
emotions.  It  is  initiated  or  increased  by  a  failure,  which  is  fre- 
quently attributed  to  the  result  of  past  indiscretion  or  excess. 

797 


798  THE  TESTICLE  [chap. 

In  treating  these  cases  it  is  necessary  to  gain  the  confidence 
of  the  patient  and  impress  "upon  him  the  fact  that  the  impotence 
is  a  common  condition,  that  it  is  temporary,  and  is  due  to  easily 
explained  and  quite  easily  treated  causes,  and  not  to  past 
excess. 

It  is  sometimes  wise  to  forbid  connection  for  a  time.  The 
general  health,  diet,  and  exercise  should  receive  attention.  The 
bowels  should  be  regulated,  the  diet  full  and  nourishing,  and 
open-air  exercise  taken.  Small  doses  of  bromides  may  be  given 
for  a  few  weeks,  and  later,  before  marital  relations  are  resumed, 
such  stimulants  as  strychnine  sulphate  (gr.  -gV  to  ^u)  ^^^  Johimbin 
hydrochlorate  (gr.  ^\)  should  be  prescribed. 

Other  drugs  and  gland  extracts  that  may  be  used  are : 
Aphrodine  chloride  (tablets,  tV  gr-);  sperminum  (essence,  20  to 
30  min.),  orchitin  (7^  gr.),  "  lymphoid  compound  capsules  "  (one 
capsule  thrice  daily),  "  lymph  serum  "  (10  min.  hypodermically). 

3.  Atonic  impotence. — Here  there  is  weakness  of  the 
lumbar  centres,  which  leads  to  absence  or  weakness  of  erection  or 
premature  ejaculation.  This  may  result  from  w^asting  disease 
such  as  phthisis,  from  ursemia,  diabetes,  ansemia,  etc.,  or  from 
poisons  such  as  lead,  antimony,  alcohol,  tobacco,  opium,  bromides, 
cocaine. 

In  the  irritative  form,  where  there  is  premature  ejaculation, 
there  is  almost  invariably  some  inflammatory  condition  of  the 
prostatic  urethra,  due  to  gonorrhoea,  stricture,  sexual  excess, 
irritating  hyperacid  or  phosphatic  urine.  These  conditions  are 
amenable  to  treatment,  and  are  discussed  elsewhere. 

STERILITY 

The  patient  is  usually  potent,  but  living  spermatozoa  are 
absent  from  the  semen.  The  number  of  sterile  husbands  in  child- 
less marriages  has  been  calculated  at  from  10  to  20  per  cent. 

There  may  be — (1)  aspermia,  absence  of  ejaculation;  (2)  oligo- 
spermia, diminished  quantity  of  semen;  or  (3)  azoospermia,  absence 
of  spermatozoa  from  the  semen. 

1.  Aspernnia. — There  may  be  a  want  of  co-ordination  of  the 
ejaculatory  muscles,  but  in  the  great  majority  of  cases  there  is 
obstruction  in  the  urethra,  which  does  not  allow  the  semen  to 
pass.  Such  conditions  are  congenital  or  acquired  stricture  of  the 
urethra,  or  disease  of  the  prostate,  such  as  tuberculous  disease, 
malignant  growth,  stone. 

Aspermia  follows  the  operation  of  suprapubic  prostatectomy  in 
32-5  per  cent,  of  cases. 

2.  Oligospermia.  —  The    quantity    of    semen   is    deficient   in 


Lxvii]  STERILITY  799 

fibrous  induration  of  the  prostate  gland  following  suppurative  or 
chronic  prostatitis. 

3.  Azoospermia  may  be  due  to  failure  of  the  testicles  to 
produce  spermatozoa,  or  to  obstruction  to  the  passage  of  sperma- 
tozoa from  the  testicle  to  the  urethra — such  conditions  as  bilateral 
atrophy,  congenital  or  acquired,  bilateral  tuberculous  disease,  syphi- 
litic disease,  or  malignant  growth  in  a  solitary  testicle.  Bilateral 
gonorrhojal  epididymitis  is  the  most  common  cause.  The  globus 
minor  is  the  seat  of  a  chronic  fibrous  nodule  which  surrounds 
and  compresses  the  duct  of  the  epididymis. 

Azoospermia  follows  prolonged  exposure  to  the  X-rays.  It  is 
not  known  whether  this  may  become  permanent  or  what  length 
of  exposure  to  the  rays  is  necessary.  Temporary  azoospermia 
follows  sexual  excess. 

Diagnosis. — The  treatment  depends  upon  a  careful  diagnosis 
of  the  cause.  The  existence  of  azoospermia  is  established  by  the 
microscopical  examination  of  the  freshly  obtained  semen.  It  is 
then  necessary  to  fuid  the  cause,  and  the  testicles,  epididymis, 
vasa  deferentia,  prostate,  and  seminal  vesicles  are  carefully  exam- 
ined for  disease.  Further,  the  urethra  must  be  examined  with 
the  urethroscope,  and  the  prostatic  urethra,  verumontanum,  and 
orifices  of  the  ejaculatory  ducts  inspected  by  the  prostatoscope. 
The  sec-retion  of  the  seminal  vesicles  and  prostate  should  be  obtained 
by  massage  and  examined  microscopically. 

Treatment. — Stricture  of  the  urethra,  prostatitis,  seminal 
vesiculitis,  and  other  conditions  must  be  treated.  Where  both 
testicles  are  atrophied  the  prognosis  is  bad  and  treatment  useless. 
Nodules  in  the  globus  minor  which  result  from  old-standing  epi- 
didymitis should  be  treated  by  short-circuiting  the  vas  deferens 
and  globus  major  (Martin's  operation).  This  should  only  be  done 
after  treating  stricture  of  the  urethra  or  other  cause  of  obstruc- 
tion (see  p.  775).  Chronic  prostatitis  with  extensive  induration  of 
the  gland  is  a  contra-indication  of  the  operation. 


PART  VIIL—THE  TUNICA    VAGINALIS 


CHAPTER  LXVIII 

HYDROCELE  AND  HEMATOCELE— NEW 
GROWTHS 

HYDROCELE 

By  kydrocele  is  understood  an  accumulation  of  fluid  in  the  sac 
of  the  tunica  vaginalis,  or  in  a  sac  in  the  cord  or  epididymis,  or 
on  the  surface  of  the  testicle  apart  from  the  vaginal  sac.  The 
common  form,  and  that  which  is  usually  denoted  by  the  unqualified 
name  of  hydrocele,  is  a  chronic  distension  of  the  sac  of  the  tunica 
vaginalis  with  fluid,  unconnected  with  disease  of  the  testicle  or 
epididymis.  There  are,  however,  numerous  other  varieties  (Fig. 
247),  some  of  which  are  frequently  observed,  while  others  are 
rare.  The  following  varieties  will  be  described  either  in  this  or 
in  the  next  chapter,  which  deals  with  the  diseases  of  the  cord : — 

Acute  hydrocele. 

Chronic  hydrocele. 

1.  Hydrocele  of  the  tunica  vaginalis.  , 

(a)  Ordinary  hydrocele. 
(6)  Congenital  hydrocele, 
(c)  Infantile  hydrocele. 

2.  Encysted  hydrocele  — of  the  cord  ;   of  the  epididymis  ; 

of  the  testis. 

3.  Diffuse  hydrocele  of  the  cord. 

ACUTE  HYDROCELE 

Acute  hydrocele  occurs  as  a  complication  of  acute  epididy- 
mitis, of  gonorrhoeal  or  other  origin ;  less  frequently  it  complicates 
orchitis.  Rarely,  it  occurs  as  the  result  of  punctured  wounds  or 
blows  or  as  a  complication  of  specific  fevers,  such  as  smallpox  or 
mumps,  with  or  without  involvement  of  the  testicle.  Acute  hydro- 
cele, the  fluid  of  which  contained  the  pneumococcus,  has  been 
known  to  complicate  pneumonia. 

800 


CHAP.  LXVIIl] 


ACUTE    HYDROCELE 


801 


The  fluid,  which  does  not  usually  exceed  3  oz.,  is  rapidly  poured 
out,  and  the  swelling  reaches  its  full  size  in  two  or  three  days. 
It  is  turbid,  and  contains  flakes  of  lymph  and  leucocytes.  An 
extensive  deposit  of  fibrin  may  take  place  in  the  wall  of  the  hydro- 
cele (fibrinous  or  plastic  hydrocele),  and  lead  to  the  formation  of 


Fig.  247. — Varieties  of  hydrocele. 

1,  Vaginal  hydrocele.     2,  Congenital  hydrocele.     3,  Infantile  hydrocele.     4,  Encysted  hydrocele 
of  cord.      5,  Interstitial  hydrocele. 

adhesions  between  the  walls  of  the  sac,  and  occasionally  to  partial 
or  to  complete  obliteration  of  the  cavity.  Suppuration  may 
follow,  and  form  an  empyema  of  the  vaginal  sac. 

Symptoms. — The  local  signs  consist  in  the  sudden  onset  and 
rapid  development  of  a  tense,  very  tender  swelling  in  the  scrotum. 
The  swelling  is  oval  or  pear-shaped,  and  the  scrotum  red  and 
2z 


802  TUNICA  VAGINALIS  [chap. 

sometimes  oedematous.  The  hydrocele  is  translucent,  but  if  there 
is  extensive  deposit  of  fibrin,  or  if  suppuration  has  taken  place, 
this  character  may  be  lost.  In  addition  to  the  pain  in  the  swelhng 
there  is  dragging  pain  along  the  cord  and  in  the  groin.  The  symp- 
toms of  a  specific  fever  or  of  acute  inflammation  of  the  epididymis 
or  testicle  are  frequently  present,  and  may  obscure  the  fever 
caused  by  the  acute  vaginalitis. 

Acute  hydrocele  in  infants  or  young  children  may  cause 
vomiting  and  prostration,  and  this,  together  with  a  tense,  irre- 
ducible swelling  at  the  external  abdominal  ring,  gives  rise  to  diffi- 
culty in  diagnosis  from  strangulated  hernia,  which  is  only  cleared 
up  on  operation. 

Treatment. — The  treatment  is  that  of  the  underlying  dis- 
ease. If  the  quantity  of  fluid  is  small  and  the  tension  moderate, 
no  special  treatment  need  be  directed  to  the  hydrocele,  but  the 
pain  of  a  large,  tense,  acute  hydrocele  is  relieved  by  tapping  with 
a  trocar  and  cannula  (p.  808). 

Should  suppuration  occur,  incision  and  drainage  should  be 
promptly  carried  out. 

CHKONIC   HYDROCELE  •      . 

Hydrocele  oe  the  Tunica  Vaginalis 

{a)  Hydrocele:   Ordinary  Hydrocele 

In  the  normal  state  the  visceral  and  parietal  surfaces  of  the 
tunica  vaginalis  are  in  contact  and  glide  upon  each  other,  being 
lubricated  by  a  small  quantity  of  fluid.  In  hydrocele  the  sac  is 
distended  by  a  large  accumulation  of  this  serous  fluid.  The 
average  age  in  this  type  of  hydrocele  is  67  years.  The  right  and 
left  sides  are  about  equally  affected  in  unilateral  hydrocele.  In 
about  one-third  of  cases  the  hydrocele  is  bilateral. 

Etiology. — In  a  small  number  of  cases  the  commencement  can 
be  traced  to  an  attack  of  epididymitis  of  urethral  origin,  or  there 
may  be  underlying  syphilitic  or  tuberculous  disease  of  the  testicle 
or  epididymis.  In  other  cases  there  is  a  history  of  initial  or  of 
repeated  injury  to  the  testicle.  One  patient  under  my  care  was 
employed  in  inspecting  and  repairing  underground  electric  wires, 
and  blamed  the  repeated  minor  injuries  received  in  descending 
through  manholes  for  the  development  of  a  very  large  vaginal 
hydrocele.  It  frequently  happens,  however,  that  the  injuries  are 
noticed  only  after  the  scrotal  swelling  has  attained  a  considerable 
size,  and  is  thus  more  exposed  to  blows.  The  wearing  of  a  truss 
for  inguinal  hernia,  and  the  occasional  appearance  of  a  hydrocele 


Lxvm] 


HYDROCELE 


803 


after  the  operation  for  varicocele,  lend  colour  to  the  view  that 
the  accumulation  of  fluid  is  in  some  cases  due  to  venous  stasis. 

In  the  majority  of  cases  no  cause,  either  local  or  general,  can 
be  found. 

The  two  chief  theories  are  that  hydrocele  is  due  (1)  to  inflam- 
mation, (2)  to  passive  congestion.  Both  of  these  theories  receive 
some  support  from  the  facts  stated  above,  but  they  do  not  suffi- 
ciently explain  the  development  of  the  great  majority  of  chronic 
hydroceles. 

Pathology. — In  recently  formed  hydroceles  the  wall  of  the 
tunica  vaginalis  is  usually  thin  and  supple,  but  where  the  hydro- 


Fig.  248. — Multilocular  thick-walled  hydrocele. 

cele  is  of  long  standing,  and  especially  where  it  has  been  exposed 
to  recurring  injuries  and  repeated  tapping,  the  serous  membrane 
becomes  thick  and  opaque,  and  a  thick,  firm  layer  of  fibrous  tissue 
forms  from  thickening  of  the  subserous  layer.  (Fig.  248.)  The 
wall  of  the  hydrocele  in  such  cases  may  measure  ^  in.  or  more  in 
thickness,  and  is  as  hard  as  cartilage.  Calcareous  deposit  may  take 
place,  and  plates  are  formed  in  the  wall.  Warty  pedunculated  tags 
may  be  found  on  the  inner  surface.  Partial  obliteration  of  the  sac 
may  result  from  adhesions  of  the  walls.  Layers  or  irregular  flakes 
of  buff-coloured  fibrin  may  be  found  adhering  to  the  wall  in  cases 
in  which  there  has  been  injury,  or  attempted  cure  by  injection  of 
irritating  fluids.  There  is  usually  a  single  cavity,  pyriform  in 
shape,   which  partly  surromids  the  testicle  and  epididymis,  and 


804 


TUNICA  VAGINALIS 


[chap. 


extends  upwards  for  a  varying  distance  along  the  cord  in  large 
hydroceles,  but  is  oval  in  the  earlier  state.  An  hour-glass  shape 
is  occasionally  observed,  where  a  constriction  which  is  due  to  a 
thickening  of  the  tunica  vaginalis  partly  divides  the  cavity  into 
two  parts  {hydrocele  en  hissac).  Multilocular  hydrocele  is  rare,  and 
the  partitions  between  the  separate  cysts  are  formed  by  adhesions. 
(Fig.  248.) 

In  large  hydroceles  a  hernia  of  the  hydrocele  sac  through  the 
coverings  of  the  testicle  may  be  found.    (Kg.  249.)    A  round  open- 


n 


Fig.  249. — ^Hernia  of  a  large  hydrocele. 

ing  the  size  of  a  halfpenny,  or  larger,  bounded  by  a  hard  ring  of 
fibrous  tissue,  can  be  felt,  and  through  this  the  serous  membrane 
prolapses  and  forms  a  soft,  secondary,  reducible  swelling  beneath 
the  skin  of  the  scrotum.  In  a  case  under  my  care  the  testicle 
became  prolapsed  through  this  ring  into  the  hernial  sac.  It  could 
be  replaced  in  the  main  sac  and  again  extruded  by  manipulation. 

The  testicle  usually  lies  below  and  behind  the  sac,  but  rarely 
it  occupies  a  position  in  front  of  the  hydrocele  and  is  in  danger 
of  being  punctured  in  tapping  the  sac.  In  recently  formed  hydro- 
celes the  testicle  is  unchanged,  but  in  an  old-standing  hydrocele 
it  is   flattened,   fibrous,   and   atrophied.     The   epididymis  is^fre- 


Lxviii]  HYDROGFXE  805 

qiieiitly  widely  separated  from  the  testicle,  and  is  elongated  and 
flattened. 

Hydrocele  fluid. — -The  average  quantity  of  fluid  found  in  a 
hydrocele  is  about  6-8  oz.  Hydroceles  of  record  size  are  those  of 
Gibbon  the  historian,  from  whose  hydrocele,  of  thirty-two  years' 
duration,  first  4  quarts,  then  a  fortnight  later  3  quarts,  then  six 
weeks  later  6  quarts  were  withdra^vn.  In  another  case,  recorded 
by  Maisonneuve,  the  hydrocele  contained  21  litres  (about  19 
quarts). 

The  fluid  is  limpid,  pale  yellow  to  deep  amber  colour,  has  a 
specific  gravity  of  1022  or  1024,  and  contains  albumin  (6  per  cent.), 
sodium  chloride,  and  carbonate  in  large  quantity.  Microscopic- 
ally, there  are  a  few  endothelial  cells,  occasionally  some  blood 
corpuscles,  and  a  very  few  leucocytes. 

The  fluid  does  not  coagulate  spontaneously,  as  the  fibrin  fer- 
ment is  lacking,  but  on  the  addition  of  blood  the  ferment  is 
supplied  and  coagulation  takes  place. 

The  fluid  may  be  dark  brown,  from  the  presence  of  altered 
blood.  In  some  old-standing  cases  it  is  charged  with  innumerable 
glittering  cholesterin  crystals,  which  settle  to  the  bottom  of  the 
glass  on  standing.  The  presence  of  these  crystals  is  unexplained. 
They  are  more  common  in  old-standing  hydroceles  than  in  those 
of  recent  origin. 

Symptoms. — A  small  hydrocele  forms  a  smooth  oval  swelHng 
in  the  scrotum,  replacing  the  testicle.  As  it  increases  in  size  it 
frequently  becomes  pear-shaped  by  extension  of  a  narrower  por-' 
tion  along  the  cord.  The  small  hydrocele  hangs  free  in  the  scro- 
tum, but  a  large  hydrocele  mounts  upwards  to  the  base  of  the 
scrotum  and  is  more  fixed.     (Fig.  250.) 

The  surface  is  smooth  and  regular,  and  the  skin,  although  it 
may  be  stretched,  moves  freely  over  the  swelling.  There  is  no 
redness  or  oedema  of  the  skin,  and  pain  and  tenderness  are  absent. 

The  consistence  varies,  but  usually  the  swelling  is  tense  and 
elastic,  and  a  faint  fluid  thrill  may  be  obtained.  The  testicle 
cannot  be  felt,  but  on  palpation  of  the  swelling  the  patient  may 
be  able  to  indicate  its  position  by  the  testicular  sensation.  Occa- 
sionally the  sac  is  lax  and  the  testicle  can  be  easily  palpated.  The 
cord  is  unaffected.  The  skin  at  the  base  of  the  scrotum  may  be 
dragged  down  by  the  large  size  of  the  swelling,  and  the  penis  may 
become  buried,  and  the  urine  issue  from  a  depression  at  the  base 
of  the  enormously  enlarged  scrotum. 

The  hydrocele  is  translucent.  The  examination  for  translu- 
cency  is  carried  out  in  a  darkened  room.  The  upper  part  of  the 
hydrocele  is  grasped  with  the  hand  nearest  the  base  of  the  scrotum 


806 


TUNICA  VAGINALIS 


[chap. 


and  squeezed  downwards  so  as  to  stretch  the  skin  of  the  scrotum 
over  it  and  make  the  sac  tense.  A  strong  electric  Hght  is  placed 
close  to  the  scrotum  behind  the  swelhng,  and  the  surgeon's  eye, 
brought  'to  the  level  of  the  hydrocele,  searches  for  translucency 
and  examines  the  position  of  the  testicle.  The  latter  throws  a 
slightly  convex  shadow,  which  appears  at  the  margin  of  some 
part  of  the  translucent  oval. 

The  hydrocele  is  not  translucent  if  the  wall  is  thick  or  calcareous. 


Fig.  250. — Hydrocele  of  tunica  vaginalis, 

nor  if  the  contents  are  purulent  or  contain  blood.  In  children  a 
scrotal  hernia  may  be  translucent. 

Dia^fnosis. — The  diagnosis  is  usually  easily  made  from  the 
characters  already  given,  but  difficulty  may  be  met  with  in  the 
following  conditions  : — 

i.  Scrotal  hernia. — A  history  can  usually  be  obtained  of  hernia 
commencing  at  the  upper  part  of  the  scrotum  or  of  hydrocele 
commencing  at  the  testicle.  The  hernia  may  diminish  or  dis- 
appear on  lying  down,  or  there  is  a  history  that  it  has  done  so ; 


Txvm]  HYDROCELE :  DIAGNOSIS  807 

it  has  ail  impulse  on  coughing  ;  it  is  resonant,  or  if  dull  has  the 
irregular  nodular  feel  of  omentum  ;  it  is  reducible  with  gurgling, 
and  the  testicle  can  be  felt  below  the  swelling.  In  a  hydrocele, 
on  the  other  hand,  there  is  no  variation  in  size,  no  impulse  on 
coughing ;  it  is  dull  on  percussion,  elastic  or  tense  or  fluctuant, 
irreducible,  and  the  testicle  cannot  be  detected  apart  from  the 
swelling.  The  diagnosis  may  be  difficult  in  an  irreducible  hernia 
and  in  children.  The  history  of  previous  reducibility  is  important. 
The  hydrocele  may  extend  along  the  cord  into  the  inguinal  canal 
and  receive  a  modified  impulse  on  coughing.  Difiiculty  may  also 
occur  in  old-standing  cases  where  the  wall  of  the  hydrocele  is 
thick  and  opaque  and  is  not  translucent. 

When  a  correct  diagnosis  cannot  be  made,  operation  should 
be  recommended  and  puncture  avoided. 

ii.  Hcematocele. — The  history  of  an  injury,  of  rapid  development 
of  the  swelling,  of  tenderness,  and  sometimes  of  the  swelling 
following  the  puncture  of  a  hydrocele,  assists  diagnosis.  There  is 
frequently  ecchymosis  of  the  skin  of  the  scrotum,  and  there 
may  be  creaking  or  crepitation  from  subcutaneous  effusion  of 
blood. 

A  hgematocele  is  not  translucent,  and  is  heavier  and  less  elastic 
to  the  touch. 

In  a  difficult  case,  puncture  or  an  incision  into  the  swelling 
will  give  the  diagnosis. 

iii.  Malignant  growth  of  the  testicle. — There  may  be  difficulty 
when  the  wall  of  a  hydrocele  is  thick  and  opaque.  Irregularity  of 
outline  and  consistence  and  steady  increase  in  size  are  important 
characteristics  of  new  growth. 

Complications,  i.  Hernia. — Inguinal  (Fig.  251)  or  scrotal 
hernia  may  coexist  with  hydrocele,  especially  where  the  latter  is 
large  and  of  long  standing.  At  first  the  two  swellings  are  distinct, 
but  at  a  later  stage  they  become  fused,  and  diagnosis  is  rendered 
difficult,  especially  when  the  hydrocele  sac  is  thick  and  opaque  and 
the  hernia  irreducible.  The  hernia  may  have  the  following  relations 
to  the  hydrocele  sac  :  (a)  It  may  lie  above  it,  either  separated 
from  it  or  closely  united  to  it.  (b)  It  may  pass  behind  it.  (c)  It 
may  invaginate  the  sac,  or  may  actually  rupture  into  it.  The 
latter  condition  may  give  rise  to  difficulty  of  diagnosis  in  a  hernia 
operation.  The  chief  points  in  diagnosis  of  a  combined  hernia 
and  hydrocele  are  the  history,  the  impulse,  reducibility,  and  tym- 
panitic note  of  the  hernia,  and  the  elastic  fluctuant  feel  and  the 
translucency  of  the  hydrocele. 

ii.  Rupture. — In  some  cases  rupture  takes  place  spontaneously 
without  any  apparent  cause,  or  more  frequently  as  the  result  of 


TUNICA  VAGINALIS 


[chap. 


traumatism,  such  as  a  kick,  a  blow,  or  violent  muscular  effort. 
I  have  seen  two  cases  of  rupture  resulting  from  coitus.  Hastings 
has  recorded  three  cases  and  reviewed  the  literature  of  the  subject. 
The  hydrocele  is  large,  and  the  wall  is  usually  the  seat  of  irregular 
fibrous  thickening,  calcification,  or  fatty  changes.  The  rupture 
is  slit-like  or  irregular,  and  may  affect  any  part  of  the  sac,  being 
slightly  more  frequent  on  the  anterior  aspect.  The  serous  layer 
of  the  tunica  vaginalis  is  usually  affected  alone,  but  the  fibrous 

layer  may  also  be 
torn.  There  is  a  tear- 
ing sensation  in  most 
cases,  not  amounting 
to  pain.  Occasionally 
the  rupture  has  taken 
place  during  sleep. 
The  swelling  grows 
large,  less  defined,  and 
softer,  and  the  scro- 
tum rapidly  becomes 
oedematous  on  the 
affected  side ;  the 
oedema  then  extends 
to  the  whole  scrotum, 
and  affects  the  penis, 
and  may  spread  to  the 
abdominal  wall  and 
perineum.  Discolora- 
tion of  the  scrotum 
appears  in  twenty-four 
hours.  The  oedema 
subsides  and  disap- 
pears, and  the  hydrocele  sac  is  found  to  be  empty.  Cure  may 
follow,  but  usually  the  sac  refills. 

iii.  Suppuration. — This  is  rare,  and  usually  follows  injury  or 
tapping,  but  may  be  spontaneous. 

iv.  Hsematocele. — A  hydrocele  may  become  filled  with  blood 
after  tapping  or  injury,  or  from  some  unknown  cause. 

Treatment. — The  treatment  is  {a)  palhative,  which  consists 
in  tapping,  or  (6)  radical,  which  includes  tapping  combined  with 
injection  of  irritating  fluids  or  various  operative  procedures. 

.  Tapping  a  hydrocele. — A  small-size  trocar  and  cannula  should 
be  selected,  as  the  larger  sizes  cause  more  pain  and  are  more  hkely 
to  injure  a  vein.  The  trocar  and  cannula  are  boiled  and  the  scrotum 
is  washed  with  antiseptic  solution,  or  a  small  area  is  painted  with 


Fig.  251. — Hydrocele  and  inguinal  hernia. 


LXVIIl] 


TAPPING    A  HYDROCELE 


809 


tincture  of  iodine.  The  position  of  tlie  testicle  is  defined  by  examin- 
ing with,  a  strong  hght.  The  surgeon  grasps  the  neck  of  the  scro- 
tum above  the  hydrocele  with  the  left  hand,  and  squeezes  the 
hydrocele  into  the  lowest  portion  of  the  scrotum,  making  the  skin 
over  it  tense  and  smooth.  (Fig.  252.)  The  trocar  and  cannula  is 
held  in  the  right  hand,  steadied  below  the  shield  with  the  fore- 
finger 1  in.  from  the  point  of  the  needle.  A  point  on  the  anterior 
surface  near  the  lower  pole  of  the  swelling  is  selected,  and  care  is 
taken  to  avoid  the  testicle  and  any  large  vein.  The  puncture  is 
made  by  a  stabbing  movement  and  with  confidence,  so  that  the 
needle  is  plunged  into  the  sac  for  an  inch  or  more. 

The  trocar  is  detached  by  pushing  the  shield  with  the  fore- 
finger and  is  then  withdrawn,  and  the  cannula  pushed  in  up  to 
the  shield.  With  the  forefinger  on  the  shield  the  cannula  is  retained 
in  position  while  the  pressure  is  kept  up  by  gradually  tightening 
the  grasp  of  the  left  hand. 


Fig.  252. — Tapping  a  hydrocele. 


The  position  of  the  hands  is  maintained  throughout  until  the 
last  drops  of  fluid .  are ;  squeezed  out,  when  the  cannula  is  with- 
drawn and  the  puncture  sealed  with  collodion. 

The  following  accidents  may  occur  : — 

i.  Puncture  of  the  testicle. — This  is  due  to  want  of  care  in  local- 
izing the  testicle. 

ii.  Incomplete  emptying  of  the  sac  from  the  cannula  slipping  out 
of  the  vaginal  sac  between  this  and  the  scrotum,  the  result  of 
neglect  to  hold  the  cannula  in  place  with  the  forefinger.  The 
fluid  infiltrates  the  scrotum.  It  is  useless  to  attempt  retapping 
then,  as  the  hydrocele  becomes  so  soft  that  the  needle  will  not 
enter.  Retapping  will  probably  be  required  in  a  week  or  ten  days. 

iii.  Hcematocele  is  due  to  puncture  of  a  large  vein  from  want 
of  care  or  the  use  of  too  large  an  instrument,  or  to  puncture  of 
the  testicle  {see  p.  815). 

iv.  Septic  complications,  su'ch  as  cellulitis,  should  not  occur. 
In  infants  a  hydrocele  may  be  tapped  by  making  a  number  of 


810  TUNICA  VAGINALIS  [chap. 

punctures  with  a  sterilized  surgical  needle.  The  fluid  oozes  away 
from  the  surface,  and  also  infiltrates  the  tissues  of  the  scrotum. 

Results  of  ta'p'ping. — In  rare  cases  a  cure  results  from  tapping 
a  hydrocele.  These  cases  are  probably  of  the  inflammatory  type, 
and  hot  the  ordinary  chronic  hydrocele.  Recurrence  takes  place 
at  a  variable  period,  usually  about  six  months,  but  sometimes 
less. 

Tapping  and  injection. — By  this  method  an  attempt  is  made, 
by  the  introduction  of  irritating  fluids  after  tapping,  to  cause 
adhesions  of  the  serous  surfaces  and  thus  prevent  recurrence  by 
obliteration  of  the  sac.  The  hydrocele  is  tapped  in  the  manner 
already  described,  and  when  the  last  drops  of  fluid  are  expressed 
\  a  syringe  containing  the  irritating  fluid  is  apphed  to  the  cannula, 

the  fluid  injected  and  the  sac  manipulated.  Part  or  all  of  the 
fluid  is  allowed  to  drain  ofl,  and  the  cannula  withdrawn. 

The  following  solutions  have  been  used,  viz.  tincture  of  iodine 
(Edin.  tincture),  2-4  drachms ;  carbolic  acid  (1  drachm  of  crys- 
talline carbolic  acid  kept  liquid  with  the  addition  of  10  per  cent, 
of  glycerine).  Of  these  the  carbolic-acid  injection  is  preferred,  as 
it  gives  less  pain.  The  patient  should  be  kept  in  bed  for  twenty- 
four  hours  and  on  the  couch  for  several  days,  after  which  he  may 
get  about  with  the  scrotum  well  slung.  Swelling  of  the  hydrocele 
appears  in  twenty-four  hours  and  begins  to  decrease  in  fourteen 
days,  disappearing  in  three  or  four  weeks. 

The  complications  of  injection  are  (1)  excessive  inflammation, 
(2)  suppuration,  (3)  slow  absorption  of  the  fluid,  (4)  recurrence  of 
the  hydrocele,  (5)  carboHc-acid  poisoning. 

The  cases  suitable  for  this  operation  are  thin-walled  hydro- 
celes of  moderate  size.  Large  hydroceles  and  those  with  thick 
fibrous  walls  are  unsuitable. 

Results. — Recurrence  takes  place  in  from  8  to  10  per  cent,  of 
cases.  Multilocular  hydrocele  may  follow.  The  results  are  some- 
what uncertain,  and  comphcations,  such  as  excessive  inflammation, 
may  ensue  and  necessitate  a  longer  convalescence  than  an  aseptic 
operation.  The  method  has  therefore  been  abandoned  by  most 
surgeons. 

Operation. — (1)  Excision  of  the  sac. — The  scrotum  is  shaved 
and  carefully  prepared.  The  hydrocele  is  made  tense  with  the 
left  hand,  and  a  longitudinal  incision  2|  in.  long  is  made  on  it 
through  the  scrotum  and  covering  of  the  testicle.  The  coverings 
are  carefully  stripped  from  the  hydrocele  sac,  which  is  then  opened 
and  the  fluid  allowed  to  escape.  The  serous  sac  is  now  stripped 
as  far  as  the  epididymis  and  the  attachment  to  the  testicle,  and 
clipped  away.     All  bleeding-points  are  very  carefully  ligatured. 


LxviiiJ        OPERATIONS   FOR  HYDROCELE  811 

Stitch  sutures  may  be  necessary,  and  occasionally  a  continuous 
suture  may  be  run  round  part  of  the  edge  of  a  thick  sac.  The 
testicle  is  returned  to  the  scrotum,  a  drain  inserted  for  twenty- 
four  hours,  and  the  scrotal  wound  stitched. 

The  patient  remains  in  bed  for  a  week,  and  then  gets  up  with 
the  scrotum  slung  in  a  suspensory  bandage. 

(2)  Jahouiat/s  O'peration. — After  exposure  of  the  hydrocele  sac 
it  is  opened  in  its  whole  length  along  its  anterior  surface,  and  each 
lateral  half  turned  backwards  so  as  to  meet  behind  the  testicle. 
The  redundant  sac  is  cut  away  and  the  edges  of  the  reduced  layers 
are  stitched  together  behind  the  testicle,  or  the  sac  is  turned  inside 
out  and  drawn  up  along  the  cord  and  stitched  in  position. 

(3)  Wyllys  Andrews'  "  hottle  "  operation. — After  exposure  of  the 
sac  and  careful  dissection  of  the  upper  pole  or  the  funicular  process, 
a  small  opening  (2  cm.  long)  is  made  at  its  extreme  upper  limit, 
the  testicle  displaced  through  this  so  as  to  lie  outside  the  sac, 
the  inverted  sac  dra-uTi  up  the  cord,  and  the  scrotal  wound  closed. 

Jaboulay's  and  Andrews'  operations  have  the  advantage  of 
rapidity,  and  there  are  no  bleeding-points  which  might  cause  a 
haematoma.  Only  a  comparatively  small  number  of  cases  have 
been  treated  by  these  methods,  and  the  results  recorded  have,  on 
the  whole,  been  good,  but  recurrence  has  taken  place  in  some 
instances.  Cases  where  the  sac  is  thick,  fibrous,  or  calcified  are 
imsuitable  for  these  operations. 

Autoserotherapy. — Gilbert  introduced  the  therapeutic  use  of 
the  patient's  0T\^^  serous  exudations  in  1894;  the  method  has 
been  extensively  used  in  cases  of  pleural  and  peritoneal  effusion, 
and  articles  have  been  published  by  Lemann  and  by  Marcon. 
Bertholou  employed  this  method  in  a  case  of  hydrocele.  He 
punctured  the  sac  with  a  hypodermic  needle  and  withdrew  2  c.c. 
of  the  fluid  and  injected  it  subcutaneously  in  the  thigh.  After  a 
second  injection  the  hydrocele  diminished  and  disappeared.  It 
had  not  recurred  in  a  month.  I  gave  the  method  a  trial  in  25 
consecutive  cases  of  hydrocele,  and  found  that  after  puncture 
and  hypodermic  injection  of  hydrocele  fluid  (30-40  minims  or 
more)  the  hydrocele  diminished,  and  in  some  cases  appeared  to 
be  cured.  Recurrence  took  place,  however,  in  all  cases  after  a 
comparatively  short  period,  varying  from  weeks  to  months.  In 
order  to  determine  whether  the  disappearance  of  the  fluid  might 
be  due  to  leakage  from  the  puncture  or  reduction  of  tension,  I 
treated  a  case  of  bilateral  hydrocele  by  puncture  and  injection  of 
fluid  from  one  hydrocele.  The  punctured  hydrocele  diminished  in 
size  and  the  fluid  almost  disappeared,  but  the  unpunctured  hydro- 
cele remained  unchanged.    I  concluded  that  the  improvement  was 


812  TUNICA  VAGINALIS  [chap. 

due  to  the  puncture,  and  corresponded  to  acupuncture  used  in 
infants. 

Following  the  idea  thus  suggested,  threads  of  silk  and  catgut 
were  introduced  through  the  hydrocele  sac,  leaving  an  inch  at 
each  end,  and  by  manipulation  this  was  drawn  under  the  skin, 
so  that  there  was  drainage  from  the  hydrocele  into  the  subcuta- 
neous tissues.  An  immediate  diminution  in  size  of  the  hydrocele 
followed,  but  the  improvement  was  not  maintained. 

LITERATURE 

Bertholou,  Journ.  de  Med.  et  de  Ohir.  Pratiques,  June  25,  1910. 

Hastings,  Lancet,  1910,  i.  916. 

Lemann,    Interstate  Med.   Journ.,  March,  1911. 

Marcon,  Presse  Med.,  Sept.  4,  1909. 

(6)  Congenital  Hydrocele 

Here  there  is  a  communication  between  the  tunica  vaginalis 
and  the  peritoneal  cavity,  due  to  the  normal  obliteration  of  this 
process  not  taking  place.  (Fig.  247,' 2.)  The  testicle  may  be  in  the 
scrotum  or  it  may  be  imperfectly  descended. 

The  hydrocele  is  noticed  soon  after  birth.  It  forms  a  pear- 
shaped,  translucent  elastic  or  fluctuating  swelling,  which  narrows 
as  it  passes  up  the  cord  to  the  abdominal  ring. 

The  swelling  increases  when  the  child  cries,  strains,  or  coughs. 
Continuous  pressure  on  the  sac  empties  it,  the  fluid  returning  to 
the  abdomen,  but  it  slowly  swells  again  when  the  pressure  is 
removed.  Sometimes  the  communication  with  the  peritoneal 
cavity  is  so  small  that  the  fluid  is  only  returned  with  great  diffi- 
culty. Congenital  hydrocele  is  most  likely  to  be  mistaken  for 
congenital  hernia.  The  features  by  which  they  may  be  distin- 
guished are  the  dullness  in  percussion  of  the  hydrocele,  the  slow 
disappearance  of  the  swelling  on  pressure  and  the  absence  of  the 
characteristic  gurgle  and  slip  of  a  hernia,  the  elastic  uniform  feel, 
the  translucency,  and  the  difficulty  of  controlling  the  swelling  by 
pressure  on  the  ring  after  reduction,  whereas  a  hernia  is  easily 
controlled. 

Treatment  consists  in  the  application  of  a  well-fitting  truss  and 
multiple  puncture  of  the  hydrocele  with  a  surgical  needle.  Should 
this  method  fail  the  sac  should  be  excised  and  the  neck  ligatured. 

(c)  Infantile  Hydrocele  and  Bilocular  Hydrocele 

In  this  form  the  tunica  vaginalis  and  the  funicular  process 

are  distended  with  fluid,  but  the  communication  with  the  peritoneal 

cavity  is  obliterated  in  the  region  of  the  external  abdominal  ring. 

(Fig.  247,  3.)    It  differs  from  congenital  hydrocele  clinically  in  the 


LXVIIl] 


ENCYSTED    HYDROCELE 


813 


impossibility  of  returning  the  fluid  into  the  abdominal   cavity. 
Multiple  puncture  will  usually  cure  the  condition. 

A  variant  of  infantile  hydrocele  is  bilocular  hydrocele,  in  which 
the  funicular  process  is  obliterated  at  the  internal  abdominal  ring. 
As  the  fluid  accumulates  the  sac  assumes  a  bilocular  form  from  the 
constriction  of  the  external  abdominal  ring  or  by  a  narrow  part 
of  the  sac  itself.  The  upper  loculus  develops  between  the  abdo- 
minal wall  and  the  peritoneum.  The  sac  should,  if  possible,  be 
dissected  out. 

Encysted  Hydro- 
cele     OP      THE 
Testis  and  Epi- 
didymis   (Sper- 
matocele) 
There  are  seve- 
ral     varieties      of 
these  cysts  : — 

(1)  IVI  ultiple 
small  cysts  of 
the  epididymis. 
— These  are  usually 
situated  in  the 
head  of  the  epi- 
didymis, and  less 
frequently  in  the 
body  or  tail.  They 
form  small  pea- 
sized  bodies,  pro- 
jecting on  the  sur- 
face of  the  head 
of  the  epididymis ; 
occasionally  they  may  become  pedunculated.  The  cysts  are  tense 
and  firm,  and  contain  a  transparent  or  turbid  fluid  in  which 
spermatozoa  may  be  found.  These  cysts  appear  after  puberty, 
and  are  more  common  after  the  age  of  40.  They  are  said  to 
arise  either  in  remains  of  the  Miillerian  duct  or  from  dilatation 
of  the  ducts  of  the  epididymis. 

(2)  Single  large  cysts  (spermatocele). — These  arise  in  con- 
nection with  the  epididymis,  either  between  the  globus  major 
and  the  testicle  or  above  the  epididymis.  (Fig.  253.)  They  are 
situated  outside  the  tunica  vaginahs,  but  may  project  into  the 
cavity.  They  are  usually  single  and  unilocular,  less  often  mul- 
tiple,  and  they  may  be  multilocular.     As  the  cyst  increases  in 


Fig.  253. — Spermatocele. 


814  TUNICA  VAGINALIS  [chap. 

size  it  separates  the  testicle  and  epididymis,  and  the  vasa  efierentia 
may  be  stretched  over  it. 

The  wall  consists  of  fibrous  tissue  lined  with  columnar  or  some- 
times flattened  epithelium.  The  fluid  is  alkaline,  opalescent,  and 
milky,  and  when  the  glass  containing  it  is  swung  round  the  cir- 
culating fluid  gives  a  remarkable  drift-cloud  or  shimmering  appear- 
ance, similar  to  that  seen  in  the  urine  in  bacilluria.  The  milkiness 
is  due  to  spermatozoa,  which  are  actively  motile  under  the  micro- 
scope.    The  spermatozoa  are  present  at  each  tapping. 

Rarely,  the  fluid  is  colourless  and  no  spermatozoa  are  present. 

Pathology. — There  are  two  views  in  regard  to  the  pathology 
of  these  cysts  : 

(1)  Retention  cyst. — Communication  between  the  cyst  and  a 
seminal  tubule  has  been  proved  by  the  injection  of  mercury  into 
the  vas  deferens  and  the  discovery  of  globules  in  the  cyst.  The 
opening  into  the  duct  will  usually  admit  a  fine  bristle. 

According  to  some  authorities,  these  cysts  are  due  to  rupture 
of  one  of  the  vasa  efferentia. 

(2)  The  second  view  is  that  the  cysts  take  origin  in  fcetal  relics  : 
{a)  The  organ  of  Giraldes  (Wolffian  body),  so  that  they  are  analogous 
to  the  parovarian  cysts  in  the  female,  (b)  The  hydatid  of  Morgagni ; 
this  is  the  remains  of  the  duct  of  Miiller,  and  is  the  analogue  of  the 
Fallopian  tube  in  the  female  :  it  normally  forms  a  small  pedun- 
culated cyst  between  the  upper  pole  of  the  testis  and  the  globus 
major,  (c)  The  vas  aberrans  ;  this  has  origin  in  the  tubules  of 
the  Wolffian  body,  and  forms  a  diverticulum  of  the  commence- 
ment of  the  vas  deferens.  The  position  of  this  body  is  against 
the  view  that  it  gives  origin  to  the  cysts. 

Encysted  hydrocele  of  the  testis  is  very  rare,  and  forms  a  single 
cyst  situated  beneath  the  tunica  albuginea. 

Symptoms. — Small  cysts  are  usually  found  accidentally  as 
rounded,  firm,  elastic  swellings  of  the  globus  major,  or  connected 
with  the  epididymis  above  and  with  the  outer  side  of  the  testicle. 
In  a  patient  who  consulted  me  there  was  sudden  moderately  severe 
pain  in  the  testicle,  followed  by  the  appearance  of  a  small,  tense, 
tender  cyst  of  the  globus  major.  Usually,  however,  small  cysts 
give  rise  to  no  pain  or  inconvenience.  Larger  cysts  approximate 
the  testicle  in  size.  There  is  an  oval  elastic  swelling  situated  imme- 
diately above  the  testicle  and  inseparably  connected  with  it,  but 
marked  ofi  from  it  by  a  groove  which  can  be  seen  on  inspecting 
the  scrotum.  The  upper  pole  may  be  larger  than  the  lower,  and 
the  cyst  resembles  an  inverted  pear.  The  cyst  grows  slowly,  and 
never  reaches  the  size  of  a  large  vaginal  hydrocele.  It  is  usually 
unilateral,  and  on  the  right  side,  but  may  be  bilateral.     When  a 


Lxviii]  H/EMATOGELE  815 

strong  light  is  used  it  is  always  translucent.  The  patient  is  often 
credited  by  his  friends  with  the  possession  of  a  third  testicle.  The 
cyst  is  distinguished  from  ordinary  hydrocele  by  the  slow  growth, 
shape,  position,  and  relation  to  the  testicle  and  the  characters  of 
the  fluid. 

Treatment. — The  cyst  rapidly  refills  after  tapping,  and  the 
only  method  of  cure  is  excision  of  the  sac. 

H.^MATOCELE 

Etiology. — Haematocele,  an  effusion  of  blood  into  the  vaginal 
sac,  may  occur  in  combination  with  hydrocele,  or  independently 
of  it. 

{a)  Haematocele  with  hydrocele. — After  tapping  a  hydrocele 
blood  may  be  rapidly  poured  into  the  tunica  vaginalis  from  punc- 
ture of  a  vessel  in  the  wall  of  the  sac,  or  from  puncture  of  the 
testicle ;  or  it  may  apparently  follow  the  rapid  removal  of  fluid 
from  a  large  hydrocele,  and  result  from  rupture  of  vessels  due  to 
lack  of  support,  injury  to  a  hydrocele,  such  as  a  blow,  or  collision 
with  the  pommel  of  the  saddle  in  riding.  Bruising  of  the  scrotum 
is  present  in  the  last-named  cases.  Occasionally  the  fluid  of  a 
hydrocele  is  found  deeply  stained  with  altered  blood  without 
any  history  of  injury  or  of  previous  tapping. 

(b)  Traumatic  hsematocele  may  rarely  develop  without  a 
hydrocele  having  been  present,  as  the  result  of  kicks,  blows,  or 
squeezes.  In  some  cases  haematocele  has  developed  after  violent 
straining,  such  as  lifting  heavy  weights  ;  here  the  blood-vessels 
are  probably  diseased.  Heematocele  may  be  associated  with  growths 
of  the  testicle.     It  occurs  in  middle  and  advanced  life. 

(c)  Spontaneous  haematocele  is  occasionally  observed  in  old 
men.  No  cause  can  be  ascertained,  and  there  is  much  difficulty 
in  making  a  diagnosis  from  growth  of  the  testicle. 

Pathology. — In  old-standing  haBmatocele  the  wall  of  the 
tunica  vaginalis  is  thickened,  and  may  be  hard  and  even  carti- 
laginous in  consistence.  The  interior  is  lined  with  layers  of  greyish 
or  brown  fibrinous  false  membranes,  lying  especially  on  the  parietal 
layer,  and  the  surface  may  be  very  irregular.  The  fluid  content 
varies  from  red  to  dark  brown,  and  its  consistence  from  that  of 
hydrocele  fluid  to  syrup.  Crystals  of  haematoidin  and  cholesterin 
may  be  found  in  old-standing  cases.  Free  clots  are  present  in  the 
fluid.  The  testicle  occupies  a  position  similar  to  that  in  hydrocele, 
but  it  cannot  be  detected  by  translucency,  and,  as  the  swelling  is 
tender,  testicular  sensation  is  no  guide.  In  old-standing  cases  the 
testicle  is  fibrous  and  atrophied. 

Symptoms. — The   sweUing   appears   rapidly   after   a   blow  or 


816  TUNICA  VAGINALIS  [chap. 

other  injury,  or  the  sac  refills  in  a  few  hours  after  tapping  of  a 
hydrocele.  There  is  pain,  sometimes  severe,  and  the  swelling  is 
tender.  Discoloration  of  the  scrotum  is  present  in  traumatic 
cases.  The  swelling  is  not  translucent.  On  tapping,  fluid  blood 
is  removed.  In  chronic  cases  there  is  a  heavy,  smooth,  hard, 
painless,  oval  swelling,  which  does  not  increase  in  size  and  is  not 
translucent,  and  on  tapping  altered  blood  is  withdrawn.  The 
cord  is  greatly  thickened. 

Inflammation  and  suppuration  are  the  chief  compHcations. 
The  infection  may  be  spontaneous,  but  it  usually  follows  punc- 
ture. The  swelling  is  tender,^  heavy,  and  painful,  the  scrotum 
reddened  and  cedematous,  and  the  temperature  high. 

Diagnosis. — (1)  Hydrocele  is  translucent  except  in  very  old- 
standing  cases.  In  hsematocele  the  swelling  is  opaque,  heaAder, 
and  harder,  with  less  elasticity.  Diagnosis  is  also  aided  by 
the  rapid  onset  and  history  of  an  injury  or  by  recurrence  after 
tapping. 

(2)  New  growths. — In  some  cases  diagnosis  may  be  impossible 
without  an  exploratory  incision.  The  steady  increase  in  size  of 
the  new  growth,  the  irregularity  of  contour  and  consistence,  the 
appearance  at  some  parts  of  bosses,  the  detection  of  hard  and 
soft  areas,  and  the  complete  loss  of  testicular  sensation,  are 
important  points. 

Treatment. — In  the  early  acute  stage  the  patient  should  be 
confiiied  to  bed,  the  scrotum  supported,  and  an  ice-bag  applied. 
After  some  days  or  a  week  the  fluid  should  be  drawn  off  with  a 
trocar  and  cannula  under  the  strictest  aseptic  precautions,  and 
moderate  pressure  apphed.  This  can  be  obtained  by  the  use  of 
a  JuUien  suspensory  packed  with  cotton-wool. 

In  old-standing  cases  operation  is  necessary.  The  sac  is  freely 
opened  and  the  contents  are  turned  out.  If  the  sac  is  supple 
and  the  testicle  apparently  healthy  the  wall  should  be  clipped 
away  as  in  hydrocele.  If,  however,  the  wall  is  thick  and  carti- 
laginous and  the  testicle  fibrous  and  atrophied,  castration  should 
be  performed. 

Chylous  Hydrocele  (Galagtocele,  Lymphocele,   Chylocele, 
Fatty  Hydrocele) 

The  tunica  vaginalis  is  distended  with  a  fluid  resembhng  chyle. 
A  small  number  of  cases  have  been  recorded,  the  majority  of  which 
have  occurred  in  tropical  countries.  The  condition  is  due  to 
obstruction  of  the  lymphatics  by  the  Filaria  sanguinis  hominis, 
and  rupture  of  lymphatic  vessels  in  the  wall  of  the  vaginal  sac. 
In  62  cases  of  filariasis  Manson  found  6  cases  of  chylous  hydrocele. 


Lxvm]  NEW    GROWTHS  817 

The  fluid  is  like  milk,  and,  on  standing,  a  layer  of  cream-like  fat 
forms  on  the  surface.  When  shaken  with  ether  the  fluid  becomes 
clear.  The  appearance  of  the  chylocele  may  be  preceded  by 
attacks  of  fever  and  pain.  Other  evidence  of  filariasis,  such  as 
elephantiasis  of  the  scrotum  and  legs,  is  sometimes  present. 

The  cyst  resembles  an  ordinary  hydrocele,  but  is  not  trans- 
lucent. Tapping  is  followed  by  rapid  recurrence.  Excision  of 
the  sac  with  the  dilated  lymphatics  of  the  cord  should  be  carried 
out. 

NEW  GROWTHS  OF   THE  TUNICA  VAGINALIS 

New  growths  of  the  tmiica  vaginalis  are  very  rare,  and  the 
few  examples  recorded  belong  to  the  mesoblastic  group  of  tumours. 

A  few  cases  of  fibroma  have  been  observed.  Makins  has 
recently  described  a  case,  and  refers  to  the  literature. 

The  fibromas  spring  from  the  subserous  layer  of  the  tunica 
vaginalis,  are  usually  single,  and  may  reach  a  large  size.  The 
tumour  envelops  the  testicle  and  is  moulded  upon  it,  the  organ 
itself  being  normal. 

Makins' s  case  was  a  .multiple  fibroma,  and  the  tumours  were 
attached  to  the  testicle,  epididymis,  and  cord.  A  similar  case  is 
described  by  Tikhonovich.  The  tumours  are  either  soft  fibromas 
or  composed  of  hard,  pale-white,  fibrillar  fibrous  tissue  in  bundles. 

Myomatous  and  fatty  degeneration  are  common,  and  necrosis 
is  frequently  present. 

Soft  fibromas  are  pyriform,  very  slowly  growing  tumours  which 
may  reach  a  very  large  size,  and  the  origin  of  which  may  be 
ascribed  to  a  blow. 

Multiple  hard  fibromas  form  a  group  of  nodules  not  unlike  a 
bunch  of  grapes.  Fibromas  are  frequently  found  in  the  cord  in 
these  cases. 

The  tumours  should  be  removed,  the  testicle  being,  if  possible, 
preserved. 

A  single  instance  of  lipoma  has  been  described  by  Park. 

Sarcoma  is  very  rare.  In  the  few  recorded  cases  there  was 
a  rapidly  forming  tumour  occurring  in  a  child  or  an  adult,  which 
was  usually  diagnosed  as  haematocele.  These  growths  are  said 
to  belong  to  the  group  of  endotheliomas. 

Pedmiculated  bodies  are  sometimes  found  in  the  cavity  of 
the  tunica  vaginalis  in  adults  and  old  men.  These  are  either  an 
enlarged  hydatid  of  Morgagni  attached  at  the  upper  pole  of  the 
testicle,  between  it  and  the  globus  major,  or  are  composed  of 
fibrous  tissue  w^hich  is  sometimes  calcified  and  forms  wart-like 
or  leaf -like  bodies  ;  they  are  attached  at  the  junction  of  the  testicle 
3a 


818  TUNICA  VAGINALIS  [chap,  lxviii 

and  epididymis,  or  scattered  over  the  serous  surface.  The  latter 
have  an  inflammatory  origin.  These  bodies  are  found  in  hydro- 
celes, and  give  rise  to  no  symptoms.  I  have  felt  such  a  body 
attached  to  the  outer  surface  of  the  testicle  near  the  upper  pole, 
giving  rise  to  iio  symptoms,  and  without  fluid  in  the  vaginal  sac. 

LITERATURE 

Ballock,  Ann.  of  Surg.,  1904,  p.  396. 

Jacobson,  Diseases  of  the  Male  Organs  of  Generation,  p.  433.     1893. 

Makins,  Proc   Roy.  Soc.  Med.,  Surgical  Section,  1912. 

Park,  Ann.  of  Surg.,  1886,  p.  365. 

Tlkhonovich,  Khirurgia  Mosk.,  x.  360. 


PART  IX.— THE  SPERMATIC  CORD 


CHAPTER  LXIX 

VOLVULUS-HYDROCELE  AND  HEMATOCELE 
NEW  GROWTHS— VARICOCELE 

Inflammatory  affections  of  the  cord  are  discussed  with  those  of 
the  testicle  and  epididymis. 

Torsion  of  the  cord  is  described  under  Torsion  of  the  Testicle. 

VOLVULUS  OF  THE   CORD 

McConnell  describes  a  singular  case  under  this  title.  A  boy 
of  15  was  seized  with  severe  pain  in  the  right  groin  when  sitting 
tailor-fashion  with  his  feet  under  him.  There  were  nausea,  vonait- 
ing,  and  collapse.  In  the  position  of  the  inner  half  of  the  right 
inguinal  canal  there  was  a  tense,  tender,  fixed  swelling,  without 
impulse  on  coughing.  The  right  testicle  was  slightly  larger  and 
the  cord  thicker  than  the  left,  but  there  was  no  pain  or  tender- 
ness. On  operation  the  distended  sac  of  an  infantile  hydrocele 
was  found  in  the  inguinal  canal,  and  projecting  into  this  was  a 
loop  of  the  spermatic  cord,  twisted  on  itself  for  two  turns,  and 
purple  in  colour  from  greatly  distended  veins.  All  the  constituents 
of  the  cord  were  included  in  the  twisted  loop.i 

HYDROCELE  OF  THE  CORD 
L  Diffuse  Hydrocele  of  the  Cord 
The  constituents  of  the  spermatic  cord  are  held  together  by 
loose  connective  tissue  rich  in  lymphatics,  and  the  whole  cord 
is  enveloped  in  a  sheath  to  which  each  constituent  of  the  abdominal 
wall  contributes  a  layer,  and  which  is  continued  down  to  cover 
the  testicle. 

The   connective  tissue   within  this   sheath  is   occasionally  the 

seat  of  diffuse  serous  infiltration,  a  form  of  .oedema  which  has  been 

termed  "  diffuse  hydrocele  of  the  cord."     The  cause  is  unknown. 

There  is  a  smooth,  cylindrical  swelling  of  the  cord,  which  is  large 

1  Lancet,  1912,  i.  1056. 

819 


820  THE  SPERMATIC  CORD  [chap. 

at  the  testicular  end.  There  is  dragging  weight,  but  no  pain. 
The  testis  and  epididymis  are  normal.  Posture  has  no  effect,  and 
the  swelling  is  irreducible. 

(From  an  omental  hernia  the  swelling  is  distinguished  by  the 
absence  or  indefiniteness  of  impulse  on  coughing,  the  irreducibility, 
the  uniform  "  feel,"  and  the  difficulty  in  defining  the  external 
abdominal  ring.  The  diagnosis  is  difficult,  and  in  a  stout  patient 
may  be  impossible  without  operation. 

Treatment  consists  in  incision  and  drainage  combined  with 
elastic  pressure. 

2.  Encysted  Hydrocele  of  the  Cord 

There  is  a  .circumscribed  collection  of  fluid  in  relation  with 
the  cord. 

The  cyst  originates  in  an  unobliterated  portion  of  the  funi- 
cular process  which  has  closed  above  and  below.  (Fig.  247,  4.)  It 
is  usually  single,  but  there  may  be  several.  The  right  side  is  the 
more  often  affected,  and  the  condition  is  found  in  children  and 
boys,  less  frequently  in  adults.  Other  forms  of  cyst  of  the  cord 
result  from  a  blood  cyst  following  trauma,  dilatation  of  the  organ 
of  Griraldes,  and  a  partly  obliterated  hernial  sac  (hydrocele  of  a 
hernial  sac). 

The  cyst  contains  fluid  similar  to  that  of  a  hydrocele  of  the 
tunica  vaginalis ;  it  may  be  mixed  with  blood  after  an  injury. 
It  forms  an  oval,  well-defined,  smooth,  elastic,  painless,  translucent 
swelling,  varying  in  size  from  a  hazel-nut  to  a  pigeon's  egg ;  it  is 
freely  movable,  and  connected  with  the  spermatic  cord. 

The  cyst  usually  hes  just  below  the  external  abdominal  ring. 
When  it  lies  in  or  immediately  outside  the  canal  it  may  be  mis- 
taken for  an  inguinal  hernia.  If  it  lies  outside  the  ring  there 
is  no  impulse  on  coughing ;  but  when  it  lies  in  the  canal  there 
is  such  an  impulse.  The  swelling  can  be  replaced  in  the  inguinal 
canal,  but  cannot  be  completely  reduced.  There  is  no  sudden 
slip,  and  no  gurgling.  Pulhng  on  the  testicle  will  sometimes 
draw  a  cyst  out  of  the  external  ring  and  allow  the  fingers  to  slip 
above  it. 

The  cyst  should  be  dissected  and  removed. 

Hydrocele  op  a  Hernial  Sac 
This  is  a  rare  condition,  in  which  the  neck  of  an  empty  hernial 
sac  is  obliterated  by  a  plug  of  omentum  or  by  adhesions  caused 
by  the  prolonged  use  of  a  truss.  There  is  a  history  of  a  swelling 
having  the  characters  of  a  hernia,  and  this  is  apparently  cured. 
Later  there  is  the  slow  development  of   an   irreducible  swelling 


Lxix]  HEMATOCELE   OF  THE   CORD  821 

which  does  not  show  variations  in  size.  The  swelhng  is  trans- 
parent, and  fluctuation  can  be  obtained.  There  is  no  impulse  on 
coughing. 

Treatment  consists  in  excision  of  the  sac. 

HiEMATOCELE  OF  THE  CORD 

1.  Diffuse  haematocele  of  the  cord  is  the  more  common  form, 
and  is  due  to  a  blow,  kick,  or  strain.  A  swelling  of  the  cord  rapidly 
forms,  and  on  palpation  may  resemble  an  omental  hernia.  The 
diagnosis  is  usually  easy  from  the  history  and  the  absence  of 
impulse,  and  from  the  fact  that  the  swelling  is  irreducible  while 
other  signs  of  strangulation  are  absent.  There  may  be  extensive 
discoloration  of  the  skin. 

In  the  early  stage,  when  the  diagnosis  is  clear,  an  ice-bag  may 
be  applied.  Later,  elastic  pressure  and  iodides  given  internally 
are  recommended.  A  very  extensive  and  increasing  haematocele 
should  be  incised,  the  clots  cleared  out,  and  a  drain  inserted. 

2.  Encysted  hsematocele  originates  either  in  haemorrhage  into 
an  encysted  hydrocele  of  the  cord  or  in  a  circumscribed  haematoma. 
There  is  a  swelling  the.  size  of  a  pigeon's  egg  or  larger,  which  is 
closely  incorporated  with  the  cord.  The  sweUing  may  have 
appeared  rapidly,  and  may  extend  downwards  and  come  into 
relation  with  the  testicle,  A  history  of  an  injury  can  usually  be 
obtained. 

Treatment  consists  in  incision,  removal  of  clots,  and  drainage. 
If  a  cyst  is  present  it  should  be  removed. 

NEW  GROWTHS  OF   THE  CORD 

Various  new  growths  of  the  cord  have  been  described,  all  of 
which  are  rare.  They  include  lipoma,  fibroma,  myoma,  myxoma, 
myxo-lipoma,  myxo-fibroma,  sarcoma,  and  carcinoma,  Stoerk  has 
described  a  rhabdo-myo-sarcoma  which  he  believed  took  origin  in 
the  vas  deferens.  There  were  metastatic  deposits  in  the  inguinal, 
retroperitoneal,  mediastinal,  and  cervical  lymph-glands. 

Lipoma  is  the  most  common  form.  It  originates  in  the  fatty 
tissue  which  is  found  among  the  constituents  of  the  cord,  or  in 
the  extraperitoneal  fat.  Whether  such  Upomas  drag  upon  the 
peritoneum  and  lead  to  the  formation  of  a  hernial  sac,  is  a  dis- 
puted point.  There  is  an  elongated,  smooth,  soft,  rounded  tumour, 
closely  related  to  the  cord  and  situated  near  the  testicle,  just 
outside  the  external  abdominal  ring  or  in  the  inguinal  canal. 
(Fig.  254.)  In  the  last-named  situation  it  may  possibly  be  dis- 
lodged by  traction  on  the  cord  and  pressure  from  above  so  that  it 
lies  outside  the  ring,  and  it  returns  to  the  canal  again  when  pressure 


822 


THE  SPERMATIC   CORD 


[chap. 


and  traction  are  relieved.  The  tumour  has  a  soft,  doughy,  or  even 
fluctuating  "  feel,"  and,  when  it  is  contained  m  the  inguinal  canal 
or  hes  just  outside  it,  closely  resembles  an  omental  hernia.  It 
is  not,  however,  reducible,  and  does  not  show  rapid  variations  in 
size.  The  tumour  may  also  resemble  an  encysted  hydrocele  of  the 
cord,  but  is  not  so  elastic  and  well  defined,  nor  is  it  translucent. 

Treatment  consists  in  dissection  and  removal  of  the  growth 
and  radical  cure  of  the  hernia,  should  this  be  present  as  a  com- 
plication. 

The  remaining  tu- 
mours of  the  cord  are 
extremely  rare. 

VARICOCELE 

This  consists  in 
enlargement  of  the 
veins  of  the  spermatic 
plexus.  A  moderate 
degree  of  varicocele  is 
said  to  exist  in  10  per 
cent,  of  male  subjects  ; 
a  marked  degree  of 
varicocele  is  much  less 
frequent.  The  left  side 
is  affected  in  the  great 
majorit}^  of  cases  (97 
per  cent.),  the  right 
side  very  rarely  (4  per 
cent.),  and  both  sides 
still  more  rarely  (2  per 
cent.)  (Corner).  Vari- 
cocele occurs  most  frequently  between  the  ages  of  15  and  26,  less 
often  in  the  next  decade,  and  rarely  after  that.  Curhng  found 
that  23  per  cent,  of  recruits  for  the  English  army  had  varicocele, 
Senn  noted  its  presence  in  25  per  cent,  of  recruits  for  the  Ameri- 
can volunteer  army,  and  French  statistics  state  that  its  frequency 
in  recruits  in  France  is  10  per  cent. 

The  spermatic  veins  leave  the  testicle  at  its  upper  end  and 
pass  upwards  in  front  of  the  vas  deferens  and  of  the  deferential 
veins.  The  veins  are  large,  intercommunicate  freely  by  lateral 
branches  surrounding  the  spermatic  artery,  and  form  a  plexus 
of  convoluted  vessels,  the  pampiniform  or  spermatic  plexus.  The 
veins  pass  through  the  inguinal  canal  into  the  abdomen,  and 
unite  to  form  two  or  three  large  veins  which  eventually  combine 


Fig.  254. — Lipoma  of  spermatic  cord  at 
external  abdominal   ring. 


Lxix]  VARICOCELE  823 

into  a  single  vein,  the  spermatic  vein,  which  opens  obhcjuely  into 
the  inferior  vena  cava  on  the  right  side  and  at  right  angles  into 
the  renal  vein  on  the  left.  The  left  spermatic  vein  is  longer  and 
larger  than  the  right.  It  is  crossed  by  the  sigmoid  flexure  of 
the  colon,  and  receives  one  or  two  colico-spermatic  veins. 

There  is  usually  a  valve  at  the  upper  end  of  each  spermatic 
vein.  This  may  be  absent  on  the  left  side,  and  in  this  case  there 
is  a  valve  in  the  renal  vein  near  the  opening.  Valves  exist  also 
in  the  veins  of  the  pampiniform  plexus. 

In  varicocele  there  is  dilatation  of  the  veins  of  the  cord,  espe- 
cially the  anterior  group,  the  pampiniform  plexus.  The  veins 
appear  to  be  greatly  increased  in  number  ;  they  are  elongated 
and  tortuous,  and  their  walls  thickened  and  rigid.  Thrombosis 
is  frequently  present.  I  have  dissected  from  a  varicocele  of 
moderate  size  a  rigid,  tortuous,  thrombossd  vein  which  felt  like 
a  very  hard  vas  deferens  and  measured  5  in.  in  length.  Phleboliths 
are  said  to  occur.  The  dilated  veins  are  massed  immediately 
above  and  behind  the  testicle,  and  diminish  in  size  and  numbers 
at  the  upper  part  of  the  cord.  Veins  covering  the  testicle  beneath 
the  tunica  vaginalis  may  also  be  dilated  and  tortuous. 

Bennett  recognizes  four  anatomical  varieties :  (1)  Varicocele 
involving  the  pampiniform  plexus  and  its  efferent  veins  and 
extending  as  far  as  the  abdomen.  (2)  Varicocele  limited  to  the 
lower  part  of  the  pampiniform  plexus.  (3)  Varicocele  involving 
especially  the  upper  part  of  the  plexus  as  far  as  the  formation 
of  the  spermatic  vein.  (4)  Varicocele  affecting  the  pampiniform 
plexus,  efferent  veins,  and  spermatic  veins. 

The  testicle  is  very  frequently  small  and  soft  when  compared 
with  its  neighbour.  This  condition  may  have  resulted  from  a 
want  of  development,  or  from  retrograde  changes  due  to  the 
varicocele. 

Etiologfy. — Numerous  theories  are  advanced  to  explain  the 
occurrence  of  varicocele,  but  nothing  definite  is  known  in  regard 
to  its  origin.  Anatomically  the  veins  have  a  very  long  course, 
are  tortuous  and  poorly  supported,  and  are  liable  to  pressure  by 
the  abdominal  muscles  in  their  passage  through  the  abdominal 
wall.  But  these  anatomical  features  are  common  to  all  subjects, 
and  what  has  to  be  explained  is  the  occurrence  of  varicocele  in 
a  few. 

In  explanation  of  the  frequency  with  which  the  left  side  is 
affected,  it  is  urged  that  the  left  spermatic  vein  is  longer  than  the 
right,  enters  the  renal  vein  at  a  right  angle,  and  is  liable  to 
pressure  from  a  loaded  sigmoid  flexure. 

The  condition  is  reasonably  held  to  be  congenital  and  to  result 


824 


THE  SPERMATIC   CORD 


[chap. 


either  from  persistence  of  foetal  veins  that  are  usually  obUterated, 
or  from  congenital  malformation  of  the  venous  plexus.  The 
following  reasons  are  given  for  upholding  the  congenital  origin  of 
varicocele  :  (1)  A  fully  developed  varicocele  may  be  found  at  an 
early  age.  (2)  The  majority  of  varicoceles  are  only  discovered 
when  fully  developed.  (3)  The  testicle  is  frequently  found  un- 
developed, arrest  of  development  having  occurred  at  an  early 
period.  (4)  There  is  an  heredity  of  varicocele  or  varix  of  the 
lower  extremity  in  half  the  cases.     (5)  Other  vascular  abnormali- 

tieB  frequently  coexist, 
such  as  varices  and 
nsevi. 

Symptoms. — The 
scrotum  is  thin,  lax, 
and  lower  than  nor- 
mal on  the  left  side, 
and  either  there  is  a 
fullness  immediately 
above  the  testicle  or 
the  veins  can  be  seen 
standing  out  promi- 
nently. (Figs.  255  and 
256.)  There  may  be 
varicose  veins  on  the 
surface  of  the  scro- 
tum. The  swelling 
increases  on  stand- 
ing, especially  if  this 
is  prolonged,  and  di- 
minishes when  the 
patient  lies  down. 
On  palpation  the 
scrotum  is  softer  than  normal,  and  the  enlarged  veins  are  felt 
like  a  bag  of  earthworms.  The  testicle  is  usually  soft,  and  often 
smaller  than  its  neighbour,  and  the  long  axis  is  infrequently 
horizontal  or  nearly  horizontal.  The  vas  is  easily  distinguished. 
Occasionally  a  thrombosed  thickened  vein  may  resemble  it,  but 
is  more  rigid  and  tortuous. 

A  slight  non-expansile  impulse  can  be  detected  on  coughing. 
When  the  patient  lies  down  the  veins  are  emptied,  and  they  refill 
on  resumption  of  the  erect  posture,  the  reflux  being  uncontrolled 
by  pressure  of  the  finger  at  the  external  abdominal  ring. 

The  patient  complains  of  a  heavy,  dragging  sensation,  and 
sometimes  of  aching  pain. 


'IH 

^1 

Hk/ 

''■.^^H 

wk 

r 

i- .  afr 

^M 

r  ' 

/^•v'mP^- 

''     « 

1 

i    ■ 

"tiSH 

A 

Fig.  255. — Varicocele. 


LXIX] 


VARICOCELE:    TREATMENT 


825 


These  symptoms  vary  very  greatly  in  different  individuals. 
Sharp  pain  is  rarely  felt.  In  examining  large  numbers  of  recruits 
for  the  Territorial  forces  I  found  that  there  were  two  well-defined 
groups.  In  one  the  subject  was  well  developed  and  robust,  and 
the  varicocele  had  frequently  escaped  his  notice  and  caused  him 
no  inconvenience.  In  the  second  class  the  subject  was  ill-grown 
and  pallid,  and  his  tissues  were  lax ;  varicose  veins  and  flat-foot 
were  frequent  concomitants.  Between  these  extremes  were  many 
gradations. 

Varicocele  occurs  in  growths  of  the  kidney,  and  a  rapidly 
developing  varicocele,  espe- 
cially on  the  right  side,  in  an 
adult  or  elderly  patient  should 
always  raise  the  suspicion  of 
renal  growth  [see  p.  198). 

Prognosis. — In  most  cases 
varicocele  tends  to  improve 
and  eventually  disappear  spon- 
taneously, and  it  is  very  rare 
in  old  men.  In  a  subject  of 
brooding  habit,  and  in  men 
of  the  ill-developed,  loosely 
built  type  to  which  I  have 
referred,  aching  pain  is  fre- 
quent and  gradually  assumes 
an  exaggerated  importance, 
and  hypochondriasis  may  de- 
velop. 

Treatment.  1.  Pallia- 
tive.—  This  consists  in  re- 
assuring the  patient  that 
atrophy  of  the  testicle  and 
impotence  will  not  occur,  in  advising  cold  baths,  regulated  exer- 
cise, tonics,  and  the  use  of  a  well-fitting  suspensory  bandage. 

2.  Operation. — This  should  be  performed  when  the  varico- 
cele is  increasing,  and  when  it  is  causing  pain  and  discomfort.  It 
is  necessary  when  admission  to  the  pubUc  services  is  desired. 
The  hard-and-fast  rule  by  which  candidates  for  the  British  Army 
who  suffer  from  varicocele  are  refused  has  been  condemned  by 
Colonel  Howard  and  others. 

General,  spinal,  or  local  anaesthesia  may  be  used.  The  vari- 
cocele is  grasped  in  the  left  hand  just  below  the  external  abdominal 
ring,  and  an  incision  1|  in.  long  is  made  into  its  upper  extremity, 
just  above  the  level  of  the  ring. 


Fig.  256. — Varicocele. 


826  THE  SPERMATIC   CORD  [chap. 

An  incision  1  in.  long  over  the  external  abdominal  ring,  trans- 
verse to  the  long  axis  of  the  cord,  has  been  used.  It  has  no 
advantage  over  the  incision  here  described. 

The  cord  is  exposed  and  the  incision  carried  through  its  cover- 
ings so  as  to  expose  the  veins.  The  vas  deferens  is  identified  and 
separated,  together  with  the  spermatic  artery  and  a  few  veins 
lying  behind  it.  These  are  returned  to  the  wound,  and  the  vari- 
cocele raised  up  on  an  aneurysm  needle.  A  strong  catgut  ligature 
is  now  passed  and  tied  round  the  veins  near  the  external  abdominal 
ring.  The  testicle  is  pulled  up,  and  a  second  ligature  is  placed 
about  2  in.  below  the  first.  The  intervening  bunch  of  veins  is  cut 
away,  leaving  a  sufficient  projection  beyond  the  ligatures  to 
prevent  slipping. 

The  ends  of  the  upper  and  lower  ligatures  are  tied  together 
so  as  to  approximate  the  two  stumps,  and  the  cut  surfaces  are 
accurately  held  together  by  one  or  two  catgut  stitches.  This 
shortens  the  cord  and  raises  the  pendulous  testicle.  If  the  scrotum 
is  unduly  lax  an  elliptical  portion  of  it  may  now  be  removed,  or 
the  most  pendulous  part  may  be  removed  in  the  following  manner  : 
An  intestinal  clamp  is  placed  transversely  on  the  scrotum  below 
the  testicles,  or  in  an  antero-posterior  direction,  and  mattress 
stitches  are  inserted  at  intervals  above  it.  The  redundant  por- 
tion of  the  scrotum  is  cut  away  below  the  clamp,  which  is  then 
removed,  the  skin  being  brought  together  by  interrupted  silk- 
worm-gut sutures.     This  procedure  is  rarely  necessary. 

The  wound  is  closed  without  a  drain.  The  patient  is  con- 
fined to  bed  for  two  days,  and  a  suspender  should  be  worn  for 
some  months  after  the  operation.  In  this  operation  the  sper- 
matic artery  is  ligatured,  and  the  blood  supply  of  the  testicle 
depends  upon  branches  of  this  vessel  which  pass  off  high  up,  and 
upon  the  deferential  artery. 

Haemorrhage  may  occur  as  a  postoperative  accident  due  to 
slipping  of  the  Hgature.  It  may  take  place  in  the  scrotum  or  within 
the  abdomen,  and  in  the  latter  position  may  be  serious  and  even 
fatal.  If  imperfectly  tied,  the  spermatic  artery  retracts  into  the 
abdomen.  The  haemorrhage  is  at  first  extraperitoneal,  but  later 
rupture  into  the  peritoneal  cavity  takes  place.  The  symptoms 
are  abdominal  pain  following  the  operation,  and  signs  of  internal 
hsemorrhage,  viz.  rapid  pulse,  pallor,  sighing  respiration,  faint- 
ing, thirst,  restlessness,  etc.  Orchitis  and  hydrocele  may  follow 
the  operation. 

Results. — Corner  states  that  fibrosis  of  the  testicle  is  present 
in  90  per  cent,  of  cases  after  operation.  It  may  have  preceded 
the  operation,  but  this  observer,  believes  that  it  is  produced  more 


Lxix]    VARICOCELE   OPERATIONS:    RESULTS    827 

rapidly  and  in  greater  degree  by  the  operation.  In  55  per  cent, 
of  cases  there  was  increase  in  the  size  of  the  testicle  due  to  this 
fibrosis.  In  some  cases  (21  per  cent.)  atrophy  of  the  testicle  has 
been  said  to  follow  radical  operation  for  varicocele.  It  is  well 
before  operating  to  draw  the  patient's  attention  to  any  lack  of 
development  of  the  testicle  that  may  exist,  since  he  is  apt  to 
attribute  to  the  operative  measures  maldevelopment  discovered 
after  the  operation. 

I  have  frequently  seen  hydrocele  of  the  tunica  vagin^is  follow 
the  operation  even  in  the  hands  of  competent  surgeons.  Corner 
found  that  it  occurred  in  23  per  cent,  of  cases,  and  appeared  soon 
after  the  operation.  It  is  the  practice  of  some  surgeons  to  incise 
the  tunica  vaginalis  and  turn  it  inside  out  at  the  time  of  the  vari- 
cocele operation  in  order  to  prevent  the  development  of  hydrocele. 
Rarely  neuralgic  pain,  present  before  the  operation,  persists  or 
even  increases.  In  the  majority  of  cases  no  further  trouble  is 
experienced  after  the  operation.  Corner  found  that  70  per  cent, 
of  these  patients  were  definitely  improved  and  well  satisfied. 

LITERATURE 

Bennett,  Brit.  Med.  Joum.,  1901,  i.  601. 

Corner  and  Niteh,  Brit.  Med.  Joum.,  Jan.  27,  1906,  p.  191. 

Hochenegg,  Zeits.  /.  klin.  Med.,  July,  1907. 

Howard  and  others,  Lancet,  Dec.  16,  1905,  p.  1786. 

Josseraud,  Nove,  Lyon  Med.,  1897,  p.  237. 

Riccioli,  //  Polidinico,  Dec.  9,  1906. 

Stoerk,  Zeits.  f.  HeilL,  1901,  S.  1. 

Thornburgh,  Med.  Eec,  Aug.  29,  1903. 


PART  X.~-THE  SCROTUM 

'  CHAPTER  LXX 

ELEPHANTIASIS— NEW  GROWTHS 

Inflammatory  diseases  and  fistulge  of  the  scrotum  are  described 
with  those  of  the  urethra  and  the  testicle. 

ELEPHANTIASIS  AND  LYMPH  SCROTUM 

Etiology. — Elephantiasis  of  the  scrotum  and  lymph  scrotum 
are  .diseases  of  tropical  climates  due  to  lymphatic  obstruction 
by  the  Filaria  sanguinis  hominis.  The  distribution  extends  from 
35°  N.  to  25°  S.  in  the  eastern,  and  from  25°  N.  to  30°  S.  in 
the  western  hemisphere.  It  is  more  common  along  sea-coasts 
and  the  banks  of  large  rivers,  and  is  especially  associated  with 
high  air  temperature  and  considerable  atmospheric  humidity, 
which  favour  the  development  of  the  filaria  in  mosquitoes  and 
its  penetration  of  the  skin  of  the  human  subject.  In  addition 
to  the  filaria,  secondary  bacterial  infection  by  a  diplococcus 
(lymphococcus  of  Dufongere)  may  perhaps  assist  in  producing 
the  disease.  Obstruction  is  not  caused  by  the  normal  embryo, 
which  measures  130  to  300  //,  in  length  and  7  to  11  /*  in 
breadth,  but  by  miniature  ova  50  fx  long  and  34  fx  in  breadth. 
These,  according  to  Manson,  are  liberated  by  some  damage,  such 
as  a  blow,  to  the  pregnant  adult  female  worm,  and  obstruct  a 
sufficient  number  of  lymph- channels  and  glands  to  cause  lymph 
stasis. 

Obstruction  may  also  be  caused  by  a  coiled  mass  of  adult 
worms  blocking  an  important  lymph-channel. 

Symptoms  and  pathology. — Lymph  scrotum  commences 
with  an  attack  of  fever  associated  with  redness,  swelling,  and 
pain  in  the  scrotum.  When  the  acute  symptoms  have  subsided 
the  scrotum  remains  swollen  and  elastic.  The  surface  is  soft 
and  smooth,  or  covered  with  rugae,  and  numbers  of  clear  vesicles 
appear.  If  these  are  punctured  they  discharge  continuously  a 
clear  lymph  or  chyle  containing  filaria  embryos,  and  this  eventually 
causes  exhaustion. 

828 


CHAP.  LXX] 


ELEPHANTIASIS 


829 


Elephantiasis  may  begin  as  lymph  scrotum,  or  there  may  be 
recurrent  attacks  of  inflammation  with  redness  and  fever,  and 
after  each  attack  the  scrotum  is  larger.  After  a  time  the  enlarge- 
ment proceeds  slowly  and  continuously  until  an  enormous  size 
is  reached,  the  largest  recorded  size  weighing  224  lb.  (Che vers). 
The  mass  is  somewhat  triangular  in  shape,  with  the  base  upwards. 
On  the  anterior  and  upper  aspect  is  a  depression  leading  into  a 


Fig.  257. — Elephantiasis  of  scrotum. 

canal  formed  by  the  inverted  prepuce,  and  at  the  bottom  of 
this  is  the  glans  penis.  The  skin  becomes  coarse  and  leathery. 
Thick  rugae  and  hypertrophied  papillae  stand  out  (Fig.  257),  a,nd 
the  mouths  of  the  folUcles  are  miusually  distinct.  Inflammation 
and  ulceration  and  sometimes  sloughing  of  the  skin  occur. 

On  section  the  skin  is  greatly  h}^ertrophied,  and  the  deeper 
layer  dense,  thick,  and  fibrous.  The  subcutaneous  tissue  is  greatly 
increased  in  bulk,  and  has  a  yellowish  cedematous  appearance, 
containing  a  large  quantity  of  fluid. 


830 


THE  SCROTUM 


[chap. 


The  thickening  of  the  skin  and  subcutaneous  tissues  is  greatest 
at  the  most  dependent  part,  and  they  get  thinner  as  they  pass 
up  towards  the  base  of  attachment.  At  the  sides  and  posteriorly 
the  skin  is  softer,  supple,  and  less  changed.  The  testicles  lie 
towards  the  back,  and  nearer  the  lower  than  the  upper  end  of  the 
mass.  Each  testicle  is  firmly  bound  down  to  the  skin  by  a  greatly 
hypertrophied  gubernaculum  testis,  and  there  is  usually  a  hydro- 
cele of  some  size  on  each  side. 

The  weight  of  the  scrotum  drags  down  the  skin  of  the  pubes 


Fig.  258. — Elephantiasis  of  scrotum  not  due  to  filaria. 

and  perineum.  A  section  of  the  base  is  triangular  with  the  apex 
backwards.     Elephantiasis  of  the  legs  is  frequently  present. 

In  rare  cases  a  non-filarial  form  of  elephantiasis  of  the  scrotum 
is  met  with.  It  is  due  to  blocking  of  lymphatics  from  -chronic 
inflammation  (chronic  ulcers,  chronic  erysipelas)  or  cicatrices,  or 
is  secondary  to  chronic  ulcers  and  recurrent  erysipelas.  Jonathan 
Hutchinson  describes  a  case  due  to  tertiary  syphilitic  inflamma- 
tion. I  have  operated  on  a  case  in  which  no  cause  could  be  dis- 
covered for  the  lymphatic  obstruction.  The  patient,  a  man  of 
45,  had  never  left  England.  Four  years  before  there  was  a  swelling 
of  the  scrotum  for  fourteen  days,  which  subsided,  and  for  two  years 
there  had  been  gradual  enlargement.  The  mass  weighed  52  oz. 
after  removal.     (Fig.  258.) 

Treatment. — In  the  early  stages  pressure  by  elastic  bandages 
is  said  to  cause  improvement,  but  when  the  disease  is  fully  estab- 


Lxx]  NEW    GROWTHS    OF    SCROTUM  831 

lished  nothing  short  of  operation  will  give  relief.  Operation  is 
Contra-indicated  in  old  or  enfeebled  patients.  The  mortality  is 
under  5  per  cent.  (Manson). 

Hernia  and  abscess  formation  should  be  treated. 

For  two  days  the  patient  is  confined  to  bed  and  the  mass 
suspended  so  as  to  empty  it,  and  before  operation  it  should  be 
emptied  as  far  as  possible  by  elastic  pressure. 

A  tourniquet  is  placed  round  the  base  of  the  mass  and  carried 
round  the  pelvis  in  a  figure  of  eight.  The  testicles  are  exposed 
by  vertical  incision  and  dissected  out,  the  hydroceles  opened  and 
inverted,  and  the  penis  exposed  and  isolated  by  slitting  up  the 
tunnel  in  which  it  is  buried.  The  incisions  are  carried  round  the 
base,  marking  out  flaps  if  feasible,  and  deepened,  vessels  being 
clamped  as  they  are  cut.  The  great  mass  consisting  of  thick 
skin  and  oedematous  areolar  tissue  is  removed.  The  flaps  are 
brought  together  and  sutured  over  the  testicles. 

LITERATURE 

Castellani  and  Chalmers,  Manual  of  Tropical  Medicine.     1910. 
Daniels  and  Wilkinson,  Tropical  Medicine  and  Hygiene. 
Manson,   Tropical  Diseases,  4th  ed.      1907. 

NEW  GROWTHS  OF  THE   SCROTUM 

Non-malignant  new  growths  of  the  scrotum  are  uncommon. 
Cutaneous  nsevi  may  be  met  with,  and  soft  and  hard  fibroma, 
lipoma,  chondroma,  and  osteoma  have  been  recorded.  Sebaceous 
cysts  may  occur  singly  or  as  multiple  tumours  (Fig.  259).  I  have 
seen  a  case  in  which  the  whole  scrotum  was  closely  set  with  round, 
hard  nodules  the  size  of  a  pea  and  larger,  and  which  proved  to  be 
sebaceous  cysts.  The  tumours  caused  no  inconvenience,  and  no 
treatment  was  desired.  Similar  cases  are  recorded  by  Hutchinson, 
Kocher,  and  others. 

A  case  of  intrascrotal  hydatid  cyst  has  been  recorded. 

Masses  of  varicose  veins  closely  set  and  with  small  telangiectatic 
spots  are  met  with  in  the  scrotum.  On  cursory  examination  the 
condition  somewhat  resembles  a  varicocele.     (Fig.  260.) 

Epithelioma  op  the  Scrotum  (Chimney-Sweep's  Cancer) 

Epithelioma  of  the  scrotum  is  more  frequent  in  chimney-sweeps 
than  in  other  males,  and  has  thus  received  the  name  "  chimney- 
sweep's cancer."  In  the  Report  of  the  Departmental  Committee 
on  Compensation  for  Industrial  Diseases  (1907)  it  is  stated  that 
the  mortality  from  cancer  among  chimney-sweeps  is  twice  that 
among   occupied   males   generally.     For   the   three   years    1900-2 


832 


THE   SCROTUM 


[chap. 


the  comparative  mortality  figure  for  cancer  among  chimney-sweeps 
between  the  ages  of  26  and  65  was  133,  as  compared  with  63  among 
occupied  males  at  the  same  ages.  The  disease  commences  in  a 
wart  (soot  wart),  most  often  at  the  lower  and  front  part  of  the 


Fig.  259. — Sebaceous  cysts  of  scrotum. 

scrotum,  and  the  whole  scrotum  may  be  covered  with  these  warts. 
The  warts  may  remain  for  long  simple,  and  then  one  of  them 
begins  to  grow  rapidly,  becomes  softer,  more  vascular,  bleeds  easily, 
and  ulcerates.  The  ulcer  spreads  slowly  along  the  skin,  the  base 
is  indurated,  the  edges  are  hard  and  everted.     Other  iorms  in 


LXX] 


CHIMNEY-SWEEP'S   GANGER 


833 


which  the  gro\vth  may  commence  are  a  nodule,  a  cauliflower 
excrescence,  or  a  horn-like  outgrowth  on  a  papilloma.  The  ulcer 
spreads  over  the  scrotum,  the  testicles  are  exposed  and  some- 
times invaded,  and  the  crura  of  the  penis  become  involved.  The 
inguinal  glands  are  enlarged  at  first  from  inflammatory  products, 
but  later  from  metastatic  deposit  from  the  growth.  Large  masses 
may  form  and  break  down,  and  ulceration  into  the  femora^  or 
ihac  arteries  may  occur.  There  is  little  tendency  to  the  production 
of  distant  metastases. 

Extension  to  the  inguinal  glands  is  usually  long  delayed,  and 
has  been  known  to 
make  its  appearance 
some  years  after  suc- 
cessful removal  of  the 
primary  disease. 

Spencer  has  shown 
that  soot  granules  are 
found  in  the  cells  of 
the  growth,  and  also 
in  healthy  skin  beyond 
the  growth. 

The  presence  of 
soot  gi'anules  in  the 
cells  of  the  epididymis 
gives  rise  to  dark 
patches  which  cannot 
be  washed  away,  and 
may  explain  the  de- 
velopment of  "  chim- 
ney-sweep's cancer  " 
years  after  the  patient  has  ceased  to  follow  his  occupation. 

The  disease  is  much  more  common  in  England  than  in  any  other 
country,  and  this  was  attributed  by  Buthn  {Brit.  Med.  Journ.,  1892, 
p.  1343)  to  the  burning  of  hard  coal  and  to  deficient  protection  of 
the  skin  from  contact  with  soot,  and  to  insufficient  washing. 

According  to  Jacobson  the  disease  is  diminishing  in  frequency. 
Labourers  engaged  in  work  among  tar  and  paraffin  are  also  liable 
to  develop  epithehoma  of  the  scrotum. 

Treatment. — This  consists  in  preventing  the  prolonged  con- 
tact of  soot  with  the  skin.  The  clothes  should  be  protective, 
and  thorough  washing  should  be  regularly  carried  out. 

Operation  should  remove  the  growth  with  a  wide  margin,  and 
the  inguinal  glands  on  both  sides  should  be  carefully  removed  with 
the  fat  in  which  they  are  embedded. 
3b 


Fig.  260. — Varicose  veins  of  scrotum. 


PART  XL— THE  PENIS 


CHAPTER  LXXI 

ANATOMY— CONGENITAL  MALFORMATIONS 
INJURIES— PREPUTIAL   CALCULI 

Surgical  anatomy. — The  penis  consists  of  three  masses  of  erectile 
tissue — the  two  corpora  cavernosa  and  the  corpus  spongiosum. 

The  corpora  cavernosa  lie  side  by  side,  and  form  the  bulk  of 
the  body  of  the  penis.  At  the  root  of  the  penis  they  separate  from 
each  other  to  form  the  crura,  which  are  attached  to  the  rami  of 
the  pubes  and  ischium,  and  are  covered  by  the  erectores  penis 
muscles.  In  the  body  of  the  penis  they  are  closely  united,  and 
at  the  anterior  part  of  the  organ  become  partly  blended,  the 
septum  between  the  two  bodies  being  vertically  perforated  to 
join  a  comb-like  partition  (septum  pectiniforme).  In  front  they 
are  united  in  a  conical  extremity  which  is  capped  by  the  glans 
penis.  The  corpora  cavernosa  are  surrounded  by  a  dense  white 
sheath  consisting  of  fibrous  and  elastic  tissue,  which  forms  a 
common  investment,  and  internally  to  which  each  has  a  separate 
capsule  of  similar  structure.  The  blood  supply  of  each  corpus 
cavernosum  is  derived  from  the  artery  to  the  crus,  a  branch 
of  the  internal  pudic  artery,  and.  some  twigs  from  the  dorsal 
artery  of  the  penis,  and  the  veins  pass  to  the  prostatic  plexus  and 
pudendal  veins  and  to  the  dorsal  vein  of  the  penis. 

The  corpus  spongiosum  lies  in  the  middle  Une  on  the  under 
surface  of  the  penis  in  a  groove  between  the  two  corpora  cavernosa. 
Posteriorly  it  expands  into  a  rounded  mass,  the  bulb,  and  anteriorly 
it  forms  a  cap,  the  glans  penis,  which  envelops  the  end  of  the 
corpora  cavernosa.  The  bulb  shows  a  superficial  median  division 
at  its  posterior  extremity.  It  is  attached  to  the  under  surface 
of  the  triangular  ligament  and  covered  by  the  bulbo-cavernosus 
muscle.  The  corpus  spongiosum  is  invested  by  a  sheath  which 
contains  more  elastic  and  less  fibrous  tissue  than  the  corpora 
cavernosa.  The  urethra  enters  the  upper  surface  of  the  bulbous 
portion  about  |  in.  from  its  posterior  extremity  and  passes  for- 

834 


CHAP.  Lxxi]    CONGENITAL  MALFORMATIONS         835 

wards  in  its  substance,  piercing  it  at  the  conical  extremity  of 
the  glans  penis. 

The  arterial  supply  enters  the  corpus  spongiosum  at  each  end, 
the  posterior  supply  being  derived  from  the  artery  to  the  bulb, 
a  branch  of  the  internal  pudic ;  the  anterior  is  the  dorsal  artery 
of  the  penis.  The  veins  pass  to  the  dorsal  veins  of  the  penis  and 
to  the  veins  of  the  bulb. 

The  skin  of  the  penis  is  thin,  elastic,  free  from  fat  or  hairs. 
Anteriorly  it  forms  the  foreskin,  and  on  the  glans  is  firmly  adherent 
to  the  spongy  tissue  and  has  no  glands.  Around  the  cervix  of 
the  penis  behind  the  glans  are  the  glands  of  Tyson,  which  secrete 
smegma. 

The  superficial  fascia  is  thick,  is  continuous  with  that  of  the 
abdominal  wall  and  scrotum,  and  contains  smooth  muscle  fibre. 
A  strong  fibrous  sheath  invests-  the  entire  organ  and  covers  the 
dorsal  vessels.  The  suspensory  ligament  is  a  strong  fibrous  band 
passing  from  the  pubic  symphysis  t:>  the  base  of  the  penis,  and 
blending  with  the  fascial  sheath  and  passing  into  the  septum 
scroti.  This  ligament  slings  the  base  of  the  penis  to  the  pubic 
symphysis.  The  lymphatics  pass  along  the  dorsum  to  the  inguinal 
glands,  while  a  few  pass  from  the  corpora  cavernosa  and  corpus 
spongiosum  to  the  pelvic  lymph-glands. 

The  development  of  the  penis  and  urethra  is  described  at  p.  392. 

CONGENITAL  MALFORMATIONS 

Rudimentary  development  of  the  penis  is  not  uncommon,  and 
the  penis  may  be  so  small  as  to  be  entirely  hidden  in  the  redun- 
dant tissues  of  the  pubes  and  scrotum.  Such  cases  have  erro- 
neously been  described  as  absence  of  the  penis.  A  penis  of 
infantile  type  may  develop  after  puberty  into  an  organ  capable 
of  procreation.  The  subject  may  in  other  respects  be  normally 
developed.  When  rudimentary  development  of  the  penis  is  com- 
bined with  a  bifid  scrotum  and  undescended  testes  the  sex  is 
diflSicult  to  distinguish.  These,  and  also  cases  of  hypertrophic  cHto- 
ris,  are  frequently  regarded  as  cases  of  hermaphroditism,  or  the  sex 
of  the  child  may  be  erroneously  diagnosed.  Neugebauer  collected 
58  cases  in  which  the  mistake  was  first  discovered  after  marriage. 

In  many  cases  it  is  impossible  to  be  certain  of  the  sex  at  birth, 
and  French  authors  recognize  a  class  of  "  sexe  indetermine."  In 
the  male  pseudo-hermaphrodite  the  descent  of  one  or  both  testicles 
into  the  folds  which  might  represent  a  bifid  scrotum  or  labia 
majora  may  take  place,  and  in  one  case  a  hydrocele  was  demon- 
strated by  its  translucency.  The  folds  are  also  more  wrinkled 
from  the  development  of  dartos  in  the  scrotum  than  in  the  labia. 


836  THE   PENIS  [chap. 

Per  rectum  nothing  will  be  felt  to  aid  the  diagnosis.  At  puberty 
characters  develop  in  most  cases  which  make  the  diagnosis  cer- 
tain— the  characteristic  development  of  pubic  hair  extending  to 
the  umbilicus  in  the  male,  the  development  of  the  prostate  felt 
per  rectum,  and  the  appearance  of  secondary  sexual  characters, 
such  as  changes  in  the  voice,  the  breadth  of  the  shoulders  as  com- 
pared with  the  pelvis,  the  appearance  of  hair  on  the  face;  and  in 
the  female  the  commencement  of  menstruation  and  the  develop- 
ment of  the  mammae. 

True  hermaphroditism  is  very  rare.  Corner  quotes  two  cases  : 
one  of  a  woman,  aged  21,  who  had  a  testicle  removed  from  an 
inguinal  hernia  (Bernard  Pitts),  and  another  of  a  man,  aged  25, 
who  had  a  uterus,  discovered  also  at  operation  (Kellock). 

Several  cases  of  absence  of  the  'penis  have  been  described,  and 
the  malformation  is  usually  combined  with  congenital  urethro- 
rectal fistula.  The  scrotum  and  testes  in  these  cases  have  usually 
been  normal  in  development. 

Torsion  of  the  penis  is  a  rare  abnormality,  and  is  not  seen  apart 
from  epispadias  or  hypospadias.  The  penis,  which  is  usually 
poorly  developed,  but  may  be  large,  is  rotated  to  the  right  one- 
quarter  of  or  a  complete  circle. 

Adhesion  of  the  skin  of  the  penis  to  the  scrotum  may  occur  alone, 
when  the  whole  under  surface  may  be  webbed,  or  in  combination 
with  hypospadias.  The  penis  is  easily  separated  and  the  edges  of 
the  wound  united.  A  hypospadias  operation  should  then  be  per- 
formed if  necessary. 

Double  penis  is  very  rare,  and  is  usually  combined  with  other 
deformities,  such  as  extrophy  of  the  bladder,  malformation  of  the 
kidneys,  additional  limbs,  or  atrophy  of  a  limb.  The  penes  may 
be  quite  separate  and  perfectly  developed,  and  functional,  or 
they  may  be  webbed.  The  testicles  may  be  normal  or  rudimentary 
and  displaced. 

Phimosis 
Narrowing  of  the  opening  in  the  prepuce  is  the  commonest 
of  all  congenital  malformations  of  the  urinary  tract.  The  pre- 
puce may  be  adherent  and  the  orifice  of  the  foreskin  narrower  ;  it 
may  also  be  long  and  project  well  beyond  the  glans  penis  as  a  loose 
process. 

Phimosis  may  be  acquired  in  adult  life  from  chronic  or  recur- 
rent balanitis,  and  in  chronic  inflammation  in  diabetes  mellitus 
in  cases  of  long  foreskin.  The  orifice  becomes  scarred  and  con- 
tracted. Acquired  narrowing  of  the  outlet  may  also  result  from 
the  scar  following  a  chancre,  from  epithelioma,  or  from  an  in- 
complete operation  for  phimosis. 


Lxxi]  PHIMOSIS  837 

Complications. — In  children  frequent  micturition  and  noc- 
turnal enuresis  are  frequent  complications.  Irritation  leading  to 
masturbation,  diflficult  micturition  with  ballooning  of  the  fore- 
sldn  and  retention,  may  result ;  and  hypertrophy  of  the  bladder, 
Avith  dilatation  of  the  kidneys,  umbilical  and  inguinal  hernia, 
prolapse  of  the  anus,  and  even  extravasation  of  urine,  are  ascribed 
to  this  cause.  Balanitis  is  a  frequent  complication  both  in  children 
and  in  adults,  and  gives  rise  to  irritation  and  discomfort  and  a 
purulent  discharge.  Gangrene  of  the  foreskin  has  been  known 
to  result.  Preputial  calculi  may  form.  The  urethra  is  infected 
from  this  source,  and  recurrent  attacks  of  urethritis  ensue. 
Stricture  has  been  stated  to  result  (Ortmann). 

Paraphimosis  is  a  common  complication,  and  in  adult  Hfe  is 
a  cause  of  impeded  coitus.  In  cases  of  long-standing  balanitis 
epithelioma  may  develop. 

Treatment. — Operation  is  necessary  on  account  of  any  of 
these  compUcations.  Gradual  dilatation  of  the  orifice  by  means 
of  forceps  is  tedious  and  unsatisfactory. 

Two  methods  of  circumcision  are  in  use  :  1.  A  pair  of  forceps 
is  placed  in  the  orifice  of  the  foreskin  and  gentle  traction  exerted 
so  that  the  foreskin  is  pulled  forwards.  A  circumcision  clamp 
(of  which  there  are  many  varieties)  is  put  obliquely  on  the  foreskin 
parallel  to  the  corona  glandis,  if  this  can  be  felt,  and  just  beyond 
the  edge  of  the  glans  penis.  The  clamp  is  held  in  the  left  hand  and 
the  forceps  and  clamp  are  cut  off  with  a  scalpel,  the  edge  of  which 
is  kept  close  to  the  clamp.  The  skin  retracts  and  the  mucous 
membrane  still  covers  the  glans.  The  edge  of  this  is  picked  up 
with  forceps,  and  is  cut  along  the  dorsum  to  the  corona  and  stripped 
off  the  glans  until  the  coronal  sulcus  with  yellow  smegma  is 
exposed.  The  redundant  mucous  membrane  is  then  clipped  away. 
Four  bleeding-points  will  usually  be  found — a  dorsal,  two  lateral, 
and  a  frsenal.  If  the  bleeding  from  these  does  not  quickly 
cease,  they  are  clamped  and  tied  with  fine  catgut,  and  catgut 
stitches  are  then  inserted  through  the  mucous  membrane  and 
skin,  bringing  them  into  accurate  apposition. 

In  children  the  womid  should  be  thickly  dusted  with  boric 
powder ;  no  dressing  is  necessary.  In  adults  a  dressing  of  moist 
antiseptic  gauze  is  kept  in  position  with  a  bandage.  After  twenty- 
four  hours  the  most  comfortable  dressing  is  boric  or  hazeline  oint- 
ment spread  on  hnt. 

2.  A  preferable  method  is  the  following :  The  foreskin  is 
retracted  until  the  orifice  is  tense,  and  on  the  edge  of  this  three 
pairs  of  fuie-toothed  forceps  are  placed — two  close  together  on 
each  side  of  the  median  fine  dorsally,  and  one  at  the  middle  fine 


838 


THE  PENIS 


[chap. 


ventrallj.  These  are  raised  and  the  foreskin  is  separated  from 
the  glans  with  a  director.  With  a  sharp-pointed  pair  of  scissors 
the  fores  iin  is  sHt  up  the  middle  Hne  on  the  dorsum  as  far  as  the 
postcoronal  sulcus,  the  edge  of  each  flap  thus  formed  being  held 
by  one  of  the  pairs  of  forceps^(Fig.  261).  The  flaps  are  well  stripped 
off  the  glans  and  corona,  and  from  the  end  of  the  dorsal  incision  a 


Fig.  261. — Circumcision. 

On  the  right,  a  dorsal  view  of  the  penis  with  forceps  in  position,  two  pairs  close  together  at  the 

dorsal  and  one  pair  at  the  freenal  margin  of  orifice  of  foreskin.      On  the  left,  the  foreskin  is 

being  cut  along  the  dorsum  and  the  further  incisions  are  marked  by  dotted  lines. 

second  is  carried  round  one  flap  of  foreskin,  leaving  just  a  narrow 
ledge  of  mucous  membrane  below  the  corona  (Fig.  262).  This  flap 
is  cut  away,  leaving  the  lower  pair  of  forceps  attached.  The 
same  incision  is  carried  round  the  second  side,  this  time  cutting 
away  the  two  remaining  pairs  of  forceps  (Fig.  263). 

Complications  of  circumcision. — 1.  Insufiicient  removal  of 
the  foreskin,  with  recontraction. 


LXXl] 


CIRCUMCISION 


839 


2.  Injury  to  the  glans. 

3.  Removal  of  too  much  skin  or  of  a  collar  of  skin  while  that 
at  the  orifice  is  left.  These  complications  occur  in  the  clamp 
method,  and  are  avoided  in  the  second  method.  The  desire  to 
"  save  something  of  the  foreskin  "  is  a  fruitful  source  of  trouble 
and  recontraction.  Haemorrhage  may  occur  in  the  subjects  of 
haemophilia,  and  may  be  fatal.     Jacobson  quotes  the  case  of  four 


Fig.  262. — Circumcision,  dorsal  view. 

The  incision  is  being  carried  round  the  right  side,  close  to  the  corona  glandis. 

Jewish  infants,  each  of  them  descended  from  a  different  grandchild 
of  a  common  ancestress  through  the  female  line,  four  generations 
back,  who  died  from  haemorrhage  consequent  on  circumcision. 
Pressure,  hot  lotion,  and  suprarenal  extract  should  be  used  in  oozing 
due  to  haemophilia. 

Paeaphimosis 
This  is  a  compHcation  of  phimosis.     The  foreskin  is  retracted 
and  the  narrow  opening  is  drawn  over  the  corona  glandis  and  can- 
not be  returned.     Balanitis  is  frequently  present  as  a  complication. 


THE  PENIS 


[chap. 


The  orifice  of  the  f  oreslcin  is  usually  rigid,  and  may  either  be  pulled 
directly  back  until  it  sUps  over  the  corona  or  may  be  rolled  back 
and  the  foreskin  reversed  as  in  normal  retraction.  When  para- 
phimosis has  developed  there  is  seen  a  thick  oedematous  collar  of 
mucous  membrane  behind  the  corona,  which  may  become  deep- 
red  or  even  purple.  Behind  this  is  a  deep  sulcus,  and  there  may 
be  another  collar,  less  prominent,  above  this,  and  sometimes  a 


Fig.  263. — ^Gircumcision,  ventral  view. 

The  right  wing  of  the  foreskin  has  been  removed,  and  the  removal  of  the  left  wing  is  nearly 
complete.     The   remaining  part  of  the   incision   passes   below   the  forceps,  as  indicated  by  the 

dotted  line. 

second  sulcus.  The  glans  is  congested,  deep-red  or  purple.  The 
site  of  strangulation  may  be  immediately  behind  the  glans  or 
farther  back.  Rarely  a  chronic  form  is  observed  following  the 
acute,  and  the  thickening  takes  the  form  of  a  solid  oedema. 

If  left  untreated  the  acute  form  goes  on  to  ulceration,  and 
relief  may  be  obtained  by  ulceration  of  the  constriction ;  very 
rarely  the  glans  becomes  gangrenous. 

Treatment. — Immediate   reduction    should    be    carried    out 


Lxxi]  INJURIES  OF  THE   PENIS  841 

whenever  possible.  The  patient  may  require  a  general  anaesthetic. 
The  penis  is  grasped  between  the  first  and  second  fingers  of  one 
hand  on  each  side,  and  with  both  thumbs  pressing  upon  the 
glans.  The  a^dematous  collar  is  pulled  forwards,  while  at  the 
same  time  the  glans  is  pressed  back.  The  traction  is  more  import- 
ant than  the  pressure.  The  oedematous  folds  may  be  punctured 
with  a  needle.  The  application  of  a  layer  of  lint  soaked  in  adrenalin 
(1  in  1,000)  and  cocaine  (10  per  cent.)  may  reduce  the  congestion 
of  the  parts  and  aid  reduction. 

If  these  measures  fail  a  longitudinal  incision  should  be  made 
on  the  dorsum  of  the  penis  through  the  oedematous  folds  and  the 
constricting  rings.  Secondary  incisions  may  be  made  to  relieve 
oedema. 

LITERATURE 

Beck,  Med.  News,  1901,  p.  451. 

Collier,  Brit.  Med.  Journ.,  1889,  i.  409. 

Corner,  Male  Diseases  in  General  Practice.     1910. 

Goschler,    Vierteljahrsch.  f.  pract.  Heillc,  1857,  S.  89. 

Hart,  Lancet,  1866,  i.  71. 

Jacobson,  Diseases  of  the  Male  Organs  of  Generation,  p.  633.     1893. 

Lorthior,   Centralhl.  f.  d.  Kranhh.  d.  Earn-  u.  Sex.-Org.,  1901,  p.  381. 

Murphy,  Brit.  Med.   Journ.,  1885,  ii.  62. 

Neugebauer,  Wien.  klin.  Bunds.,  1902,  p.  631. 

Sangalll,  Ann.  d.  Mai.  d.  Org.  Gen.-  Urin.,  1895,  p.  478. 

INJURIES   OF    THE   PENIS 

Wounds  of  the  penis  are  usually  incised,  rarely  punctured, 
and  are  produced  intentionally  in  certain  sects,  maliciously  from 
jealousy,  or  by  barbarians  in  war,  or  accidentally. 

In  deep  wounds  the  haemorrhage  is  abundant  if  the  penis  is 
erect  at  the  time  of  the  injury,  but  may  be  comparatively  trifling 
if  it  is  flaccid. 

When  the  organ  is  incompletely  severed  the  urethra  may 
escape.  If  the  urethra  is  cut  across,  the  end  will  retract  and 
retention  of  urine  occurs.  In  complete  amputation  the  haemor- 
rhage should  be  arrested  by  ligature  of  the  arteries  and  by  stitch- 
ing the  edges  of  the  sheath  of  the  corpora  cavernosa  together. 
The  urethra  must  be  identified  and  drawn  up  and  stitched  to 
the  skin,  and  a  catheter  tied  in. 

In  partial  section  the  haemorrhage  should  be  controlled  by 
accurate  suture  of  the  fibrous  sheath  of  the  corpora  cavernosa. 
When  the  penis  remains  attached  by  a  small  segment  a  catheter 
should  be  tied  in  and  an  attempt  made  by  accurate  suture  to 
obtain  adhesion.  The  functional  result,  though  not  at  first  good, 
may,  after  some  months,  be  satisfactory.  During  convalescence 
the    patient    should    be    kept   under    the   influence   of   morphia, 


842  THE  PENIS  [CHAP. 

belladonna,   and  bromides  in  order  to  prevent   erections,  which 
seriously  interfere  with  healing. 

The  skin  of  the  penis  and  scrotum  may  be  torn  away  by 
the  bite  of  an  animal.  Immediate  Thiersch  grafting  should  be 
done  to  prevent  cicatricial  contraction,  or  a  transverse  flap  of 
skin  may  be  raised  on  the  pubes  and  the  penis,  with  a  catheter 
in  the  urethra  inserted  under  this.  When  the  flap  is  adherent 
to  the  under  surface  of  the  penis  it  is.  cut  from  the  abdominal 
wall,  leaving  sufficient  to  wrap  around  the  penis.  The  two  wings 
meet  on  the  dorsum. 

Wounds  from  firearms  are  rare,  and  the  indications  for  treat- 
ment are  the  same  as  those  from  cutting  instruments.  Contusion 
is  seldom  met  with,  and,  apart  from  the  injury  to  the  urethra 
which  may  result,  recovery  is  usually  rapid.  Gentle  pressure 
and  the  use  of  an  ice-bag  are  indicated. 

Fracture  of  the  erect  penis  may  occur  during  connection.  In 
some  cases  periurethral  induration  around  a  stricture  has  been  a 
predisposing  cause.  When  the  accident  has  occurred  pain  was 
felt  so  severe  as  to  cause  fainting.  The  pain  radiates  to  the  pubis 
and  groin.  Several  patients  have  stated  that  there  was  a  sound 
like  the  breaking  of  a  glass  rod.  The  organ  suddenly  becomes 
flaccid,  and  this  is  followed  by  enormous  swelling  from  infiltration 
with  blood.  If  rupture  of  the  urethra  takes  place  there  are  haemor- 
rhage from  the  meatus,  pain  on  micturition,  and  infiltration  of 
urine  or  complete  retention. 

The  sequelae  of  this  injury  are  traumatic  stricture  and  impair- 
ment of  erection.  The  proximal  segment  becomes  erect,  but  the 
distal  segment  beyond  the  site  of  fracture  remains  flaccid  or  may 
become  erect  later.  In  order  to  avoid  these  results,  Eeclus  advises 
that  the  fracture  be  treated  by  incision,  clearing  out  of  the  clots, 
and  suture. 

Dislocation  of  the  penis  has  been  recorded  in  a  few  cases. 
The  skin  of  the  penis  remains  in  position,  the  attachment  of  the 
sldn  behind  the  glans  is  torn,  and  the  glans  and  body  are  dis- 
placed into  the  subcutaneous  tissue  of  the  pubes,  scrotum,  or 
groin. 

Rupture  of  the  urethra  and  subsequent  infiltration  of  urine 
may  complicate  the  diagnosis.  The  penis  should  be  replaced  in 
its  cutaneous  sheath  and  retained  by  stitches,  and  the  urethra 
repaired. 

Strangulation  of  the  penis  may  occur  by  accident,  as  from 
the  use  of  a  jugum  penis  for  the  treatment  of  incontinence, 
or  in  erotic  individuals  from  instruments  such  as  a  ring.  Con- 
gestion and  oedema  of  the  peripheral  segment  results,  the  penis 


LxxiJ  PREPUTIAL    CALCULI  843 

becomes  enormously  swollen,  and  retention  of  urine  follows.  If 
relief  is  not  obtained  sloughing  takes  place,  and  urinary  fistulse 
may  form.  The  treatment  consists  in  removing  the  strangulating 
body  by  the  use  of  vaseline  and  massage  in  the  earlier  stages, 
or  by  cutting  it  across  with  a  chisel  or  pliers  if  this  is  possible. 

LITERATURE 

Bagaraze,  Ann.  d.  Mai.  d.  Org.   Oen.-  Urin.,  1908,  p.  1028. 
Duplay  et  Reclus,  Traite  de  Ghir.,  1899,  vii.  1250. 
Hagen,  Bessel,  Arch.  f.  klin.  Ghir.,  1902,  p.  75. 
Powers,  Ann.  of  Surg.,  1909,  p.  238. 

PREPUTIAL  CALCULI 

A  high  degree  of  phimosis  is  present,  and  almost  all  the  cases 
occur  in  adults,  children  being  rarely  affected.  The  number  of 
calcuh  varies.  Lewin  found  from  1  to  10  calculi  in  six  cases, 
15  in  one  case,  and  between  38  and  70  in  eight  cases  ;  Lloyd 
found  11,  weighing  70  gr. ;  Jacobson  11,  Corney  22,  and  Vincent 
200  small  calcuh.  The  size  varies  from  that  of  a  pea  to  that  of 
a  man's  fist. 

The  composition  varies  according  to  the  origin.  Kaufmann 
divides  the  calculi  into  three  classes  : 

1.  Preputial  calcuh  composed  of  smegma  impregnated  with 
lime  salts.  These  are  soft,  friable  masses  consisting  of  epithelium, 
cholesterin,  fatty  acids,  and  hme,  with  numerous  bacteria. 

2.  Preputial  calcuh  arising  in  stagnant  urine  in  the  prepuce. 
These  are  harder,  and  may  show  some  lamination.  The  chief 
constituents  are  uric  acid,  calcium  phosphate,  ammonio-magnesium 
sulphate,  with  traces  of  carbonic,  oxahc,  and  sulphuric  acids. 

3.  Migrating  vesical  calculi,  which  are  arrested  in  the  dilated 
foreskin.  A  calculus  may  ulcerate  through  the  floor  of  the  fossa 
navicularis  and  lodge  in  the  preputial  sac. 

The  constant  symptom  is  a  copious  purulent  discharge,  and 
pain  and  difficult  micturition  are  frequently  present.  The  calcuh 
can  be  felt  as  a  hard  mass  in  the  foreskin,  and  grating  can  in 
many  cases  be  elicited. 

LITERATURE 

Bland-Sutton,  Brit.  Med.  Joum.,  1907,  i.  1412. 

Blodgett,  Boston  Med.  and  Surg.  Joum.,  June  21,  1900. 

Croft,  Trans.  Clin.  Soc,  xviii.  8. 

Kaufmann,   Verletzungen  und  Krankheiten  der  mdnrdichen  Harnrohre  und  Penis 

1886. 
Lloyd,  Brit.  Med.   Joum.,  1882,  ii.  580. 
Louis,  La  Grece  Medicate,  1899,  No.  7. 
Sutton,  Walton,  Lancet,  Aug.  18,  1900. 


CHAPTER  LXXII 

BALANITIS— HERPES  PR^PUTIALIS  —  CEDEMA  OF 
PENIS — PRIAPISM — FIBROUS  C AVERNOSITIS— 
TUMOURS 

BALANITIS— BALANO-POSTHITIS 

Balanitis  means  inflammation  of  the  glans,  and  posthitis  inflam- 
mation of  the  foreskin. 

Apart  from  venereal  balano-posthitis,  which  is  the  most  common 
variety,  inflammation  under  the  foreskin  may  arise  from  a  number 
of  causes.  Non-venereal  balanitis  is  subacute.  It  occurs  in  the 
subjects  of  phimosis,  and  may  result  from  intercourse  with  a 
woman  affected  with  leucorrhoea,  or  from  want  of  cleanliness, 
leading  to  accumulation  and  decomposition  of  smegma.  It  is 
frequently  met  with  in  patients  who  are  looked  upon  as  gouty. 

Balanitis  also  occurs  in  diabetes,  and  the  inflammation  may 
spread  to  the  penis  and  scrotum,  causing  a  very  painful  form  of 
eczema. 

The  inflammation  usually  commences  in  the  sulcus  behind 
the  corona  glandis,  and  leads  to  constant  burning  and  itching. 
A  purulent  discharge  appears  from  under  the  foreskin,  and  if 
neglected  this  may  become  fetid.  Superficial  ulceration  may  be 
found  on  the  glans  and  inner  surface  of  the  foreskin. 

A  rare  form  occurs  with  intensely  red  shining  patches  on  the 
surface  of  the  glans.  The  margin  is  sharply  defined,  and  there 
is  no  irritation  or  uneasiness.  Long-continued  balanitis  is  a  pre- 
disposing cause  of  epithelioma.  Diphtheritic  and  croupous  forms 
have  been  described. 

Treatment. — Occasional  attacks  of  balanitis  are  treated  by 
washing  with  a  solution  of  bicarbonate  of  soda  or  lead  lotion,  or, 
after  washing  the  parts  thoroughly  with  soap  and  water  and  care- 
fully drying,  tannin  and  glycerine  (glycerinum  acidi  tannici,  B.P.) 
should  be  apphed  with  a  cotton- wool  dab ;  and  this  is  repeated 
night  and  morning.  The  general  health  and  diet  should  receive 
attention,  and  the  urine  should  be  tested  for  sugar.  Diabetic 
balanitis  may  be  treated  on  the  same  lines,  or  a  dusting  powder 

844 


CHAP.  Lxxii]  HERPES    PR^PUTIALIS  845 

may  be  prescribed  containing  boric  acid,  starch,  and  zinc  oxide,  or 
protection  to  the  skin  given  by  smearing  with  zinc  oxide  oint- 
ment. The  effect  of  general  and  dietetic  treatment  is  very  marked 
in  these  cases.  In  persistent  balanitis  circumcision  should  be 
recommended,  and  the  danger  of  the  development  of  epithelioma 
pointed  out. 

In  diabetic  balanitis  operation  should,  if  possible,  be  avoided. 
In  persistent  and  severe  cases  circumcision  should  be  done  under 
local  anaesthesia  and  with  the  strictest  antiseptic  precautions. 

HERPES  PRiEPUTIALIS 

True  herpes  zoster  of  the  penis  is  a  rare  condition,  and  differs 
in  no  way  from  that  seen  elsewhere. 

The  common  variety  has  been  called  catarrhal  herpes,  and  is 
an  erythema  (Jacobson). 

The  disease  occurs  in  young  or  middle-aged  men.  The  onset 
may  be  preceded  by  digestive  disturbance,  such  as  dyspepsia 
and  flatulence,  and  in  recurrent  attacks  these  prodromata  may 
be  recognized  by  the  patient  as  a  certain  warning  of  the  onset. 
Nervous  depression  may  also  be  noted.  There  is  intense  itching 
and  burning,  and  a  red  blush  appears  on  the  inner  surface  of  the 
foreskin  near  the  sulcus,  and  less  frequently  on  the  glans  or  on 
the  cutaneous  surface  of  the  foreskin  or  the  skin  of  the  penis. 
A  group  of  tiny  papules  appear,  and  these  become  vesicles  and 
then  pustules.  If  protected,  they  shrivel  in  a  few  days  and  a 
dark  scab  forms,  which  is  thrown  off,  and  heahng  has  taken  place. 
Usually  friction  of  the  clothes  rubs  off  the  pustules,  and  tiny 
round  punched-out  superficial  ulcers  remain  in  groups.  The 
"  attack  "  lasts  five  to  six  days,  but,  if  care  is  not  taken  to  pro- 
tect the  ulcers  and  observe  strict  cleanliness,  secondary  infections 
may  prolong  the  disease.  In  such  cases  there  are  enlargement  and 
tenderness  of  the  groin  glands.  There  is  a  tendency  for  herpes 
to  recur  at  definite  intervals,  usually  of  a  few  weeks  or  months, 
and  it  may  persist  in  this  intermittent  form  for  some  years, 
gradually  diminishing  in  frequency  and  severity,  and  eventually 
disappearing.  The  immediate  cause  of  these  attacks  may  occasion- 
ally be  ascribed  to  dietetic  errors  or  sexual  excesses. 

The  relation  of  herpes  to  venereal  diseases  has  been  much 
discussed.  Syphihtic  patients  and  those  who  have  suffered  from 
soft  sore  are  more  Uable  to  develop  this  condition,  but  it  frequently 
occurs  when  there  has  never  been  venereal  disease,  and  occasion- 
ally when  there  has  been  no  sexual  intercourse. 

Diagnosis.— In  the  ulcerative  stage  herpes  is  distinguished 
from  soft  chancre  by  the  sequence  of  papule,  vesicle,  and  pustule, 


846  THE   PENIS  [chap. 

the  grouping  of  the  ulcers,  and  the  sHght  reaction  of  the  surround- 
ing tissues,  and  frequently  by  the  history  of  previous  attacks  ; 
from  syphilitic  chancre  by  the  absence  of  induration  and  of  adenitis, 
the  history  of  the  local  conditions,  and  occurrence  within  a  few 
days  after  connection.  Scrapings  of  the  surface  may  be  examined 
for  the  Spirochseta  pallida. 

Treatment. — Careful  washing,  followed  by  the  use  of  an 
ointment  or  dusting  powder  as  in  balanitis,  to  act  as  a  protective 
layer,  prevents  infection  and  spread.  Lead  lotion  may  be  used, 
and  forms  a  deposit  on  the  ulcer.  The  most  efficacious  treat- 
ment is  to  apply  nitrate  of  silver  solution  (2-4  per  cent.)  on  a 
pledget  of  cotton- wool  so  that  a  white  layer  forms  over  each  ulcer. 
One  application  may  suffice.  Arsenic  is  recommended  as  a  pre- 
ventive medicine,  and  should  be  tried  in  recurring  cases. 

Circumcision  has  not  given  good  results,  the  vesicles  appear- 
ing elsewhere. 

(EDEMA  OF   THE   PENIS 

Acute  oedema  of  the  skin  of  the  penis,  usually  confined  to  the 
foreskin  but  occasionally  involving  the  whole  penis,  is  observed 
in  venereal  diseases,  and  occurs  as  a  result  of  paraphimosis,  com- 
pression of  the  penis  by  rings,  extravasation  of  urine,  and  as  an 
insignificant  part  of  oedema  due  to  systemic  diseases. 

In  rare  instances  acute  oedema  develops  as  an  isolated  pheno- 
menon without  apparent  cause.  I  have  met  with  three  cases 
in  which  sudden  acute  oedema  occurred  in  young  and  middle- 
aged  men.  There  had  been  no  venereal  disease  for  ten  or  more 
years.  The  onset  was  sudden  and  without  any  warning.  The 
skin  was  shiny  and  translucent  in  appearance,  and  the  oedema 
ceased  at  the  base  of  the  penis.  After  lasting  from  three  days 
to  a  week  the  swelling  rapidly  or  gradually  disappeared.  No 
evidence  of  phlebitis  of  the  dorsal  vein  or  any  cause  for  lymphatic 
obstruction  could  be  found.  In  one  case  there  had  been  several 
attacks  at  intervals  of  a  year  or  more. 

Chronic  oedema  of  the  penis  may  occur  as  a  part  of  elephantiasis. 
Where  extensive  scarring  is  present  in  both  groins  from  bygone 
suppuration  or  (in  one  case)  extensive  dissection  of  tuberculous 
glands,  chronic  oedema  of  the  penis  may  be  present  (Fig.  264) ; 
or  the  lymphatic  drain  may  stifl&ce  under  ordinary  conditions, 
but  is  inadequate  when  some  sHght  attack  of  balanitis  occurs  and 
the  penile  skin  swells  up  from  time  to  time. 

Treatment. — ^No  local  treatment  is  usually  necessary  in  idio- 
pathic oedema ;  but  multiple  punctures  may  afiord  rehef .  In 
more  chronic  conditions  all  causes  of  local  irritation  should  be 


Lxxfi]  PRIAPISM  847 

removed  and  massage  applied  to  the  groins.  Lymphatic  drainage 
by  buried  strands  of  catgut,  after  Handley's  method  for  oedema 
of  the  arm  in  breast  tumours,  may  be  tried. 

PRIAPISM 

This  term  denotes  continuous  erection,  which  is  usually 
extremely  painful,  and  is  unaccompanied  by  desire  or  emission. 

Some  local  cause  may  be  present,  such  as  injury,  acute  or 
chronic  inflammation,  or  new  growth.     Or  priapism  may  be  due 


Fig.  264. — Chronic   oedema   of  penis   due  to  extensive  scarring 
following  operations  on  both  groins. 

to  disease  of  or  injury  to  the  cervical  or  upper  dorsal^spinal  cord. 
In  some  cases  it  is  reflex :  Hobbs  describes  a  case  having  a  nasal 
origin.  It  occurs  occasionally  in  leukaemia.  The  cause  is  at 
present  obscure.  Priapism  has  been  ascribed  to  thrombosis,  to 
nervous  influences,  to  the  pressure  of  a  haematoma  on  the  veins, 
and  to  vaso-motor  influences.  The  onset  is  often  sudden.  The 
corpora  cavernosa  only  are  rigid.  There  is  constant  severe  painj 
and  micturition  is  difficult.  The  condition  may  last  several  weeks — 
three  or  six — or  even  months,  but  recovery  usually  takes  place. 
Treatment. — Sedatives  (bromides,  camphor,  morphia,  chloral) 
may  be  tried  and  ice-bags  applied,  but  these  measures  have  proved 


848  THE  PENIS  [chap. 

ineffectual.  Incision  of  the  corpora  cavernosa  and  evacuation  of 
the  contents  has  been  immediately  successful,  but  the  ultimate 
result  has  been  a  complete  loss  of  erection. 

FIBEOUS    CAVERNOSITIS— INDURATION    OF    THE 
CORPORA  CAVERNOSA 

In  this  condition  there  is  a  fibrous  induration  of  the  sheath 
or  in  the  substance  of  the  corpora  cavernosa. 

Etiology. — The  average  age  in  20  cases  of  primary  indurative 
cavernositis  under  my  care  was  56|  years ;  one  patient  was  aged 
30,  and  one  48  ;  the  others  were  all  over  50.  There  are  two  dis- 
tinct classes  of  cavernositis — that  which  follows  a  recognized  local 
cause,  and  that  which  appears  spontaneously. 

1.  Secondary  indurative  cavernositis. — Gonorrhceal  urethritis  is 
the  most  frequent  cause,  and  the  induration  succeeds  an  old- 
standing  periurethritis.  Gummatous  infiltration  is  a  less  common 
cause  (cavernositis  syphilitica).  Induration  of  the  cavernous  tissue 
may  follow. injury  such  as  contusions  or  fracture  of  the  penis  or 
wounds. 

2.  Primary  indurative  cavernositis  was  first  described  by  Kirby, 
of  Dublin,  and  is  comparatively  uncommon.  I  have  notes  of 
20  cases  that  have  passed  through  my  hands  in  eight  years. 

Gout,  diabetes,  or  rheumatism  is  sometimes  present,  and  the 
sclerosis  may  be  ascribed  to  one  of  these  diseases.  Tuffier  in  26 
collected  cases  found  gout  in  15  and  diabetes  in  11.  Dupuytren's 
contraction  may  be  present. 

Smallpox,  typhoid  fever,  pysemia,  and  exanthemata  have  been 
noted  as  causes,  but  in  many  cases  no  cause,  either  local  or  general, 
can  be  found  to  explain  the  sclerosis.  Sacher  gives  the  frequency 
of  different  causes  in  187  collected  cases  as  follows :  Diabetes  and 
gout  23-5  per  cent.,  syphihs  11  per  cent.,  gonorrhcEa  9  per  cent., 
traumatism  8-2  per  cent.,  rheumatism  2-1  per  cent. 

Pathological  anatomy. — The  induration  may  be  in  the  form 
of  a  nodule,  a  plaque,  or  a  cord.  The  nodule  is  rounded,  regular, 
and  sohtary  or  multiple,  and  several  may  coalesce.  Plaques  vary 
in  thickness,  and  cords  are  frequently  nodular  and  situated  in  the 
middle  line  on  the  dorsum.  They  are  hard,  sometimes  cartilaginous 
in  consistence.  When  due  to  fracture,  stricture,  or  other  local 
cause,  the  induration  may  involve  the  tmiica  albuginea  of  the 
corpus  cavernosum  and  extend  into  the  cavernous  tissue.  In 
primary  indurative  cavernositis  the  sclerosis  is  confined  to  the 
tunica  albuginea  and  the  septum.  In  the  primary  form  the  in- 
duration consists  of  tissue  similar  to  a  cheloid.  There  is  hard, 
fibrous  tissue  with  embryonic  cells  and  very  few  blood-vessels. 


LXXll] 


INDURATIVE    GAVERNOSITIS 


849 


Symptoms. — The  patient  complains  of  curvature  of  the  penis 
during  erection  {le  strabisme  penien).  The  curve  may  be  to 
the  right  or  the  left,  or  towards  the  pubes,  or  very  rarely  down- 
wards, according  to  the  position  of  the  induration,  which  occupies 
the  concavity  of  the  curve. 

There  may  be  pain  on  erection,  and  connection  is  frequently 
impossible.     Delayed  ejaculation  is  often  present.     In  severe  cases 


Fig.  265. — Indurative  cavernositis  of  sheath  of  left  corpus 
cavernosum  ;    penis  displaced  to  right. 

there  is  distortion  of  the  penis  in  the  flaccid  condition,  the  penis 
being  turned  towards  the  sound  side  (Fig.  265).  In  some  cases 
the  portion  of  the  penis  beyond  the  indurated  mass  remains  flaccid 
when  erection  occurs. 

The  onset  is  insidious  in  primary  sclerosis,  but  may  be  sudden 
in  traumatic  cases.  There  is  a  hard  nodule  or  a  plaque  in  the 
sheath  of  the  corpus  cavernosum  or  along  the  septum. 

The  most  frequent  situation  is  at  the  base  of  the  penis  on  the 
3c 


i/ 


850 


THE  PENIS 


[chap. 


dorsum,  and  there  is  usually  a  saddle-shaped  plaque,  which  spreads 
laterally,  involving  part  of  the  circumference.  (Fig.  266.)  With 
or  without  this  plaque  a  hard  cord  may  be  felt  along  the  middle 
line  on  the  dorsum.  Plaques  or  nodules  may  be  found  at  other 
parts  of  the  corpora.  The  anterior  ends  of  these  bodies  may  be 
afiected  so  that  the  mass  feels  buried  in  the  base  of  the  glans  penis. 
The  skin  is  freely  movable  over  the  mass. 

The  sclerosis  may  extend  to  the  under  surface  of  the  corpora 
cavernosa,  and  the  urethra  and  corpus  spongiosum  are  felt  like 
a  gutter  between  the  lateral  masses. 

Diagnosis. — The  diagnosis  is  not  difficult.     The  cartilaginous 


Fig.  266. — Diagrams  of  distribution  of  fibrous  induration  in 
14  consecutive  cases  of  indurative  cavernositis. 

hardness,  the  absence  of  signs  of  syphilis,  and  the  effect  of  anti- 
syphilitic  treatment  distinguish  the  indurations  from  gummata. 
Malignant  infiltration  of  the  corpus  cavernosum  is  always  secondary 
to  epithelioma  of  the  glans  or  prepuce ;  it  is  more  deeply  seated 
in  the  cavernous  tissue,  and  has  a  rapid  course. 

Course  and  prognosis. — Primary  indurative  cavernositis 
slowly  extends,  but  after  a  time  becomes  stationary.  There  is 
no  tendency  to  resolution.  Cartilaginous  transformation  appears 
to  have  occurred  in  one  instance.  Ossification  has  not  been 
authenticated.  Sachs  found  calcification  in  three  cases  on  X-ray 
examination. 

Treatment. — The  effect  of  treatment  is  disappointing.  Iodide 
of  potash  and  arsenic  have  been  recommended,  and  local  applica- 
tions of  iodide  of  potash,  mercury,  iodoform,  and  salicylates  are 


Lxxii]  DERMOID   CYST   OF   PENIS  851 

used.  Applications  of  the  faradic  current  have  been  unsuccess- 
ful. Electrolysis  has  in  rare  cases  been  followed  by  improve- 
ment. Subcutaneous  injections  of  thiosinamin  ethyl  iodide,  3  gr., 
or  iodolysin,  15  minims,  may  be  tried.  In  one  case  I  used  local 
injections  into  the  fibrous  mass  of  fibrolysin  (thiosinamin  and 
sodium  salicylate,  15  per  cent.),  2-3  c.c,  and  the  induration  dis- 
appeared. Excision  has  not  been  successful  in  relieving  the 
deformity. 

LITERATURE 

Hopezansky,  Wien.  Jclin.  Woch.,  xxi.  318. 
Kirby,  Dublin  Med.   Journ.,  1850. 
Trlllat,  Oaz.  des  Hop.,  1902,  1045. 
Whitacre,  N.Y.  Med.  Journ.,  March  19,  1910. 
Wolbarst,  Themp.  Gaz.,  June  15,  1900. 

TUMOURS  OF   THE  PENIS 

Dermoid  cysts  are  very  rare.     They  occur  as  small  pea-sized 
bodies  in  or  close  to  the  median  raphe  on  the  under  surface  of 
the  penis.     In  a  young  man 
aged  31,  mider  my  care,  .there 
was  a  raised,  round  swelling  ,«-'^ 

the  size  of  a  small  pea  in  the 
skin   immediately  to  the  left     / 
of   the   median   raphe,    1   in.     I  ,, 

behind  the  glans  on  the  ven- 
tral   surface    of    the    penis. 
(Fig..  267.)     He   had    noticed     pig.  267.— Dermoid  cyst  of  penis; 
it  since  it  began  to  discharge  displaced  raphe. 

a  little  clear  fluid  eight  years 

previously.  There  was  a  tiny  granular  bud  on  its  surface,  and 
a  little  clear  fluid  could  be  expressed.  On  section  the  cyst  wall 
consisted  of  squamous  epithelium. 

Mucous  cysts  have  also  been  described,  and  sebaceous  cysts 
are  sometimes  seen. 

A  horn  composed  of  epithelium  growing  from  the  glans  penis 
has  been  described.     Such  cases  are  pathological  curiosities. 

Examples  of  lipoma,  fibroma,  angioma,  and  chondroma  have 
been  recorded. 

Papilloma 

Soft  warts  are  usually  venereal  in  origin,  but  occasionally 
are  non-venereal.  They  are  usually  collected  in  the  sulcus 
behind  the  corona  glandis  or  on  the  foreskin.  (Fig.  268.)  The 
skin  of  the  glans  may  also  be  affected.    They  are  soft  and  friable, 


852 


THE  PENIS 


[chap. 


Fig.  268. — Venereal  warts  on  glans  penis 
and  foreskin. 


and    bleed   easily.      It    has    been    shown    that   these   papillomas 
may    become    malignant    and    infiltrate    the    penis. 

Treatment. — 
The  warts  should  be 
removed  with  curved 
scissors,  and  solid 
nitrate  of  silver  ap- 
plied to  the  base. 
Pressure  should  be 
used  to  control  bleed- 
ing, and  adrenalin 
may  be  applied  to 
stop  any  troublesome 
oozing. 

Epithelioma 

Malignant  growths  of 
the  penis  are  of  compara- 
tively frequent  occurrence. 
They  form  2J-3  per  cent, 
of  all  malignant  growths. 

Etiology. —  The  dis- 
ease is  chiefly  met  with 
between  the  ages  of  50 
and  70,  is  rare  before  45, 
and  is  most  common  at 
the  age  of  55.  Cases  oc- 
curring at  the  ages  of  21 
and  30  have,  however, 
been  described. 

Phimosis  is  an  import- 
ant predisposing  cause. 
Epithelioma  frequently  de- 
velops where  phimosis  is 
present.  Demarquay  found 
that  42  out  of  59  cases  of 
epithelioma  of  the  penis 
had  phimosis.  Epithe- 
lioma in  this  situation  is 
very  rare  among  the  Jews 
(Travers). 

The  long  foreskin  en- 
courages the  development 
Fig.  269.— Epithelioma  of  penis.  of    chronic   balanitis,   and 


LXXIl] 


EPITHELIOMA  OF  PENIS 


853 


long-continued  balanitis  attributable  to  this  cause,  or  of  the  type 
asci'ibed  to  gout,  is  a  predisposing  cause  of  epithelioma. 

Epithelioma   may   develop   in  venereal   warts,  scars   from  old 


Fig.  270. — Epithelioma  of  penis,  enlargement  of  groin  glands, 
oedema  of  right  leg. 


854  THE   PENIS  [chap. 

chancres,  or  in  gummatous  induration.  Leucoplakia  is  a  rare 
precancerous  condition. 

Injuries  such,  as  tearing  of  the  frsenum  have  been  the  starting- 
point  of  mahgnant  disease.  Infection  of  the  glans  penis  from 
carcinoma  of  the  cervix  has  been  recorded  in  isolated  cases. 

Pathology. — The  epithehoma  commences  more  frequently  on 
the  foreskin  than  on  the  glans  penis,  but  when  the  patient  comes 
under^  observation   both  are  usually  affected.     Kaufmann   states 


\ 
\ 


'iX 


Fig.  271. — Partial  amputation  of  penis  for  epithelioma  of  glans. 

The   orifice   of  the  foreskin  has  been  closed  over  the  growth  with  stitches,  which  are  used  for 
traction.     Incision  for  amputation  with  ventral  flap. 

that  out  of  33  cases  the  foreskin  was  first  affected  in  20  and  the 
glans  in  13.  The  growth  usually  begins  as  a  wart  (87  per  cent.), 
as  ai  deeply  seated  nodule,  or  in  an  ulcer.  In  the  majority  of 
cases  it  forms  a  papillomatous  or  cauliflower-like  growth,  or  it 
may  be  composed  of  nodules.  (Fig.  269.)  A  phimosis  is  usually 
present  and  covers  the  growth.  The  end  of  the  penis  becomes 
greatly  increased  in  circumference  and  club-like,  and  it  is  fre- 
quently impossible  to  draw  back  the  foreskin  in  order  to  inspect 
the  growth. 


LXXIl] 


EPITHELIOiMA  OF  PENIS 


855 


A  less  common  form  is  an  epitheliomatous  ulcer  with  irregular 
depressed  base  and  indurated  rolled-over  margin.  A  rare  form 
infiltrates  the  glans  penis. 

Extension  takes  place  along  the  lymphatic  channels  or  into 
the  corpora  cavernosa.  The  lymphatics  pass  along  the  dorsum 
and  sides  of  the  penis  to  the  innermost  group  of  the  horizontal 
groin  glands,   which  lie  in  close  relation  to  the  internal  saphena 


Fig.  272. — Partial  amputation  of  penis. 

Ventral  flap  formed  ;  corpus  spongiosum  with  urethra  cut  across  and  dissected  up. 

vein  and  the  femoral  vein.  Lymphatic  spread  takes  place  com- 
paratively early.  Kaufmann  found  that  the  glands  were  normal 
in  only  8  out  of  48  cases.  The  fibrous  sheath  of  the  corpora 
cavernosa  resists  the  invasion  of  the  growth  for  a  long  time,  but 
eventually  it  is  destroyed,  and  in  a  few  cases  the  cavernous  tissue 
is  invaded.  Narrowing  of  the  urethra  may  be  observed,  but  the 
wall  is  rarely  destroyed.  Metastases  to  viscera  such  as  the  lungs 
and  Uver  are  rare. 

Histologically  the  growth  is  a  squamous  epithelioma. 

Symptoms. — When  phimosis  is  present  the  patient  complains 


856 


THE  PENIS 


[chap. 


of  a  purulent  and  sometimes  fetid  discharge,  which  is  frequently- 
blood-stained.  As  already  mentioned,  there  is  enlargement  of 
the  end  of  the  penis,  which  may  assume  very  considerable  pro- 
portions. (Fig.  270.)  Only  partial  retraction  of  the  foreskin  is 
possible,  and  an  irregular  warty  bleeding  mass  is  seen.  In  the 
ulcerative  form  an  epitheliomatous  ulcer  with  irregular  base  and 
heaped-up,  sometimes  irregular  and  warty  edges,  is  seen.  The 
meatus  of  the  urethra  is  in  some  cases  invaded.     There  may  be 


Fig.  273. — Partial  amputation  of  penis. 

Two   views   of  stump.      The   severed  corpora   cavernosa    and  the  longer  corpus  spongiosum 
containing  the  urethra  are  seen. 

difficulty  in  micturition.  Pain  is  usually  absent  until  a  late 
stage,  and  when  it  appears  is  of  a  neuralgic  character,  radiating  to 
the  groins  and  down  the  thighs.  Haemorrhage,  beyond  staining  the 
purulent  discharge,  is  exceptional.  Painful  erections  may  occur. 
The  lymphatic  glands  of  the  groin  are  enlarged  at  a  comparatively 
early  period.  Cachexia  occurs  late.  The  duration  extends  over 
two,  three,  or  four  years. 

Diagnosis. — When  phimosis  is  present  the  fetid  sanious  dis- 
charge and  enlargement  of  the  glans  penis  may  lead  to  a  diagnosis, 
but  it  may  be  necessary  to  slit  up  the  foreskin  before  the  nature 
of  the  disease  is  evident. 


LXXIl] 


AMPUTATION   OF   PENIS 


857 


If  any  doubt  remains  a  portion  of  the  growth  should  be  removed 
and  examined  microscopically. 

Treatment. — Radical  treatment  is  indicated  in  all  but 
advanced  cases.  It  is  contra-indicated  by  cachexia,  visceral 
metastases,  and  any  considerable  metastasis  to  the  lymph-glands. 

Amputation  of  the  penis. — This  may  be  performed  by  means 
of  a  flap  or  circular  or  elliptical  incision.  A  tourniquet  (a  rubber 
catheter)  is  placed  around  the  base  of  the  penis  and  a  flap  marked 
out  on  the  dorsum  of  the  organ  extending  on  each  side  to  half  the 
circumference.  (Fig.  271.)  This  is  raised  from  the  tunica  albu- 
ginea,  and  the  skin  of 
the  ventral  surface,  the 
corpus  spongiosum,  and 
the  urethra  are  cut  across 
at  the  level  of  the  base 
of  the  flap,  and  the  ure- 
thra is  dissected  out. 
(Fig.  272.)  Ligatures  are 
placed  on  the  dorsal  ves- 
sels and  the  principal 
arteries  of  the  corpora 
cavernosa.  The  tunica 
albuginea  of  the  corpora 
cavernosa  is  united  across 
the  face  of  the  cut  cav- 
ernous tissue.  (Fig.  273.) 
The  dorsal  flap  is  punc- 
tured near  its  lower  ex- 
tremity, and  the  urethra 
brought  through  this  opening,  split,  and  stitched  down.  The  skin 
wound  is  then  closed.  (Fig.  274.)  In  the  elliptical  incision  the 
urethra  is  cut  obliquely  and  the  skin  united  to  the  edge  of  the 
urethra  all  round.  This  operation  should  be  performed  when 
the  disease  is  confined  to  the  glans  penis  or  extends  less  than 
an  inch  beyond  it.    The  inguinal  lymph-glands  should  be  removed. 

Complete  amputation  of  the  penis:  Thiersch-Gould  oper- 
ation. (Figs.  275-9.)  The  patient  is  placed  in  the  lithotomy  position 
and  an  elliptical  incision  made  around  the  base  of  the  penis  and 
carried  down  along  the  middle  line  to  the  mid-point  of  the  peri- 
neum. A  sound  is  placed  in  the  urethra,  the  scrotum  is  spht, 
and  the  bulb  exposed.  The  urethra  is  cut  across  with  about 
2  in.  of  the  bulb,  and  left  hanging.  The  suspensory  ligament  is 
cut  across  and  the  penis  dissected  do^s^Tiwards,  the  crura  being 
detached  from  the  rami  of  the  pubes  and  ischium  by  means  of 


,/4^ 


Fig.  274. — Partial  amputation  of  penis. 

Flap  covering  end  of  sturap  and  urethra  appearing 
through  opening  near  base  of  flap. 


858 


THE  PENIS 


[chap. 


a  raspatory.  The  scrotum  is  brought  together,  and  the  urethra 
brought  down  to  the  perineal  part  of  the  wound,  trimmed,  and 
stitched  to  the  skin.  The  groin  glands  are  then  removed  by  a 
curved  incision  with  the  convexity  downwards.     The  dissection 


Fig.  275. — Complete  amputation  of  penis  (Thiersch-Gould 
operation). 

Scrotum  split  and  retracted  ;   incision  carried  round  base  of  penis. 

o£  the  fat  and  glands  proceeds  from  without  inwards,  and  it  may 
be  necessary  to  ligature  the  internal  saphenous  vein. 

Total  emasculation  is  sometimes  performed,  and  consists  in 
removal  of  the  testicles  and  the  penis. 

Results. — Good  results  are  obtained  in  suitable  cases  by  partial 


LXXIl] 


AMPUTATION   OF  PENIS 


859 


or  by  total  amputation  of  the  penis  combined  with  removal  of  the 
groin  glands.  Of  100  cases  Dellinger-Barney  found  recurrence  in 
39  per  cent,  in  the  first  year  and  16  per  cent,  in  the  second 
and  third  years.     Only  12   per  cent,  of  cases  showed  recurrence 


Fig.  276. — Complete  amputation  of  penis. 

Crura  dissected  up,  bulb  split,  and  urethra  cut  across. 

after  five  years.  Survivals  of  three  to  ten  years  are  not  un- 
common, and  survivals  of  twelve  and  twenty-nine  years  are  also 
recorded. 

A  patient  who  came  under  my  care  is  well  without  recurrence 
six  years  after  partial  amputation  of  the  penis  with  removal  of 


860 


THE  PENIS 


[chap. 


epitheliomatous  groin  glands.  In  total  emasculation  for  very 
extensive  growths  survivals  without  recurrence  for  one  year,  fifteen 
and  sixteen  months,  and  three  years  have  been  recorded. 


Fig.  277. — Complete  amputation  of  penis. 

Penis   turned  down  and  dissected  off  pubic  symphysis  and  triangular  ligament ;  [  dorsal 

vessels  ligatured. 

Saecoma  and  Endothelioma 

These  growths  are  very  rare.  Legueu  found  only  18  recorded 
cases  of  sarcoma.  The  growth  is  round-celled,  mixed-celled,  or 
spindle-celled,  and  melanotic  sarcoma  has  been  observed.  Lymph- 
glands,  lungs,  and  liver  are  early  involved.  Sarcoma  is  much 
more   rapid    in    its   development   and   course    than   epithelioma. 


LXXIl] 


AMPUTATION   OF  PENIS 


861 


The  enlarged  glands  may  reach  an  enormous  size.  A  few  cases 
of  endothelioma  have  been  recorded.  The  results  of  operation 
for  'sarcoma  have  been  very  unsatisfactory,  the  majority  of  the 
patients  dying  within  a  few  months. 


Fig.  278. — Complete  amputation  of  penis. 

Penis  has  been  removed  ;   stump  of  urethra  is  seen. 

LITERATURE 

Bland-Sutton,    Tumours,  Innocent  and  Malignant,  5th  eel.      1911. 

Cholzoff,  Zeits.  /.   Urol.,  1910,  p.  649. 

Colmers,  Zieglers  Beitr.,  1903,  p.  285. 

Dellinger-Barney,  Ann.  of  Surg.,  1907,  p.  890. 

Demarquay,  Maladies   Ghirurgicales  de  Penis.     1877. 

Englisch,   Centralbl.  /.  d.  Krankh.  d.   Ham-  u.  Sex.-Org.,  1902,  p.  36. 


862 


THE  PENIS 


[chap,  lxxii 


Fig.  279. — ^Gomplete  amputation  of  penis. 

Operation  completed  ;   urethra  implanted  in  perineum. 


LITERATURE  (continued) 

Jacobson,  Diseases  of  the  Male  Organs  of  Generation.     1893. 

Kautmann,   Verletzungen  und  Krankheiten  der  mannlichen  Harnrohre  und  Penis. 

1886. 
Kuttner,  Beitr.  z.  klin.  Ghir.,  1900. 

Legueu,  IP  Congres  de  la  Soc.  Internat.  de  Chir.,  1908,  ii.  63. 
Mermet,  Bev.  de  Chir.,  1895,  p.  382. 
Shield,  Lancet,  1900,  i.  75. 
Steiner,  Deuts,  Zeits.  f.  Ohir.,  1906,  p.  363. 


INDEX 


Abscess,  lacunar,  complicating  gonorrhoea, 
605 

perincphritic  \sci:  Perincphritic  ab- 
scess) 

periurethral,  647 

— —  perivesical,  517 

prostatic,  679 

renal,  153 

•  "  urinary,"   647 

Absence  of  bladder,  393 

of  kidney,  67 

of  penis,  836 

of  prostate,  675 

■  of  senainal  vesicles,  744 

of  testicles,  756 

— • —  of  ureter,  312 

of  urethra,  569 

Actinomycosis  of  bladder,  453 

of  kidney,  245 

Adeno-carcinoma  of  bladder,  473 

of  female  urethra,  663 

Adenoma  of  bladder,  470 

of  kidney,  186 

Adenomatous  polypi  of  urethra,  658 

theory  of  enlarged  prostate,  690 

Adrenal   tumours    {see   Suprarenal   gland, 

tumours  of) 
Albuminuria  in  chronic  prostatitis,  681 

in  renal  tuberculosis,  232 

Ammonium-urate  calculi  of  kidney,  254 
Amputation  of  penis  in  epithelioma,  857 

in  tuberculosis,  666 

Anastomosis  in  hydronephrosis,  180 
in  injuries  of  ureter,  309 

in  surgical  wounds  of  ureter,  310 

pyelo-ureteral,  181 

■  uretero-intestinal,  342 

■  uretero-rectal,  399 

•  uretero-renal,  339 

uretero-ureteral,  180,  340 

uretero -vesical,   340 

Andrews's  (Wyllys)  "  bottle  "  operation,8ii 
Aneurysm  of  renal  artery,   109 

^ —  — —  diagnosis  of,   no 

• etiology  of,   109 

• pathology  of,  109 

prognosis  in,   no 

symptoms  of,   no 

•  treatment  of,  no 

Angioma  of  bladder,  488 
Anorchism,  756 
>4jiuria,  15 

after  internal  urethrotomy,  641 

calculous,  278 

diagnosis  of,  281 

etiology  of,  278 


Anuria,  calculous,  pathology  of,  278 

• period  of  intoxication  in,  280 

of  tolerance  in,  280 

prognosis  in,  282 

symptoms  of,  279 

treatment  of,  282 

circulatory,   16 

from  loss  of  renal  tissue,  19 

from  nephrectomy,  297 

hysterical,   16 

in  injury  of  kidney,  100 

in  polycystic  kidney,  210 

in  pyelonephritis,  ascending,  132 

— ■ —  infective,   18 

reflex,  16 

treatment  of,   19 

•  urinary  tension,   18 

Arterio-sclerotic  theory  of  enlarged  pros- 
tate, 690 

Arthritis,  gonorrhceal,  605 

Ascending  pyelonephritis  {see  Pyelone- 
phritis, ascending) 

Aspermia,  798 

Atonic  impotence,  798 

Atony  of  bladder,  385,  532 

— — •  treatment  of,  539 

— — -  without  obstruction,  537 

without  signs  of  nervous  dis- 
ease, 537 

Atrophy  of  prostate,   728 

of  seminal  vesicles,  745 

of  testicle,  755 

after  orchitis,  777 

Autoserotherapy   in    hydrocele    of   tunica 

vaginalis,  8n 
Azoospermia,  799 

Bacilluria,  51 

diagnosis  of,  54 

etiology  of,  51 

in  tuberculosis  of  prostate,  688 

pathology  of,  51 

prognosis  in,  54 

treatment  of,  general,  54 

serum,  55 

•  vaccine,  55 

Bacteriuria  {see  Bacilluria) 
Balanitis,  844 

complicating  gonorrhoea,  604 

Balano-posthitis,  844 

Beck's  operation  for  glandular  hypospadias, 
579 

Biers  treatment  of  gonorrhoeal  rheu- 
matism, 606 

Bilharzia  haematobia,  445 

— • 7-  life  history  of,  446 


863 


864 


INDEX 


{see  Vesical  calculus) 
of     (see     Carcinoma 


of 


of 


Bilharziosis  of  bladder,  445 

complications  of,  450 

etiology  of,  445 

mode  of  infection  in,  445 

pathology  of,  446 

prognosis  in,  451 

symptoms  of,  450 

treatment  of,  451 

of  kidney  and  ureter,  246 

Bilocular  hydrocele  of  tunica  vaginalis,  813 
Bladder,  344 

absence  of,  393 

actinomycosis  of,  453 

adeno -carcinoma  of,  473 

■ adenoma  of,  470 

■ angioma  of,  488 

— —  arteries  of,  347 

■  atony  of  {see  Atony  of  bladder) 

bilharziosis    of    {see    Bilharziosis 

bladder) 

calculus  of 

carcinoma 

bladder) 

changes  in,  in  nervous  disease,  533 

cholesteatoma  of,  471 

— ■ — ■  chondro -sarcoma  of,  488 
•  chorion-epithelioma   of,    488 

congenital  malformations  of,  392 

cystoscopic  appearance  of,  365 

dermoid  cysts  of,  488 

development  of,  392 

dilatation  of,  congenital,   394 

diverticula    of    {see    Diverticula    of 

bladder) 

double,  395 

drainage,  546 

in  cystitis,  433 

methods  of,  547 

perineal,  546 

suprapubic,  547,  549 

— ■ in  rupture  of  urethra,  593 

— — -  epithelioma  of,  cylindrical,  473 

• squamous,  472 

examination  of,   352 

• ■  by  catheters,  353 

by  cystoscopy,  362 

by  exploration,  360 

by  inspection,  352 

by  palpation,  352 

by  sounds,  357 

by  X-rays,  360 

per  rectum,  352 

per  vaginam,  353 

•  extroversion  of  (see  Extroversion  of 

bladder) 

■  fibroma  of,  486 

•  fibro-myoma  of,  487 

fistulffi  of   {see  under  Fistula) 

foreign  bodies  in,  514 

hernia  of  {see  Cystocele) 

— — ■  hypertonic,  531 

■ inflammation  of  {see  Cystitis) 

injuries  of,  416 

inversion  of,  409 

lymphatics  of,  348 

membranes  in,  395 

myoma  of,  487 

myxoma  of,  487 

myxo-sarccmia  of,  488 


Bladder,  nerves  of,  348 

nervous  diseases  of,  531 

treatment  of,  538 

operations  on,   541 

papilloma     of     {see     Papilloma     of 

bladder) 

physiology  of,    349 

prolapse  of,  409 

relations  of,  345 

rhabdo-myoma  of,  488 

rupture  of  {see  Rupture  of  bladder) 

sarcoma  of,  487 

spasm  causing  incontinence  of  urine, 

379 
in  nervous  disease  of  bladder, 

531 

in  papilloma  of  bladder,  469 

sphincter  of,  346 

^  "  stammering,"   385 

state  of,  in  injury  of  nervous  system, 

538 

surgical  anatomy  of,  344 

symptoms  in  nervous  diseases,  535 

syphilis  of,  452 

veins  of,  348 

wall  of,  346 

washing  in  cystitis,  432 

in    tuberculous   cystitis,   444 

wounds  of,  420 

{see  also  Vesical) 

Blood  calculi,  254 

Bottini's  galvano-cauter}'  operation,  730 

Bright's  disease  {see  Nephritis) 

Bubo,  suppurating,  in  gonorrhoea,  605 

Bucknall's  operation,  580 

Cachexia  in  malignant  tumour  of  kidney, 

198 
Calcium-carbonate  calculi,  vesical,  493 
Calcium-phosphate  calculi,  renal,   254 
Calculous  anuria  {see  Anuria,  calculous) 
Calculus  of  seminal  vesicle,  752 
preputial,  843 

prostatic  {see  Prostatic  calculus) 

renal  {see  Renal  calculus) 

ureteral  {see  Ureteral  calculus) 

urethral  {see  Urethral  calculus) 

vesical  {see  Vesical  calculus) 

Cancer  {see  Carcinoma) 

"  Capitonnage "  in  hydronephrosis,  179 
Capsulotomy  in  chronic  Bright's  disease, 

161 
Carcinoma  of  bladder,  471 

alveolar,  473 

complications  of,  478 

course  of,  478 

cystitis  type  of,  476 

•  cystoscopy  in,  477 

■  diagnosis  of,  476 

■  examination  in,  477 

hasmaturia  type  of,  477 

spread  of,  473 

■  symptoms  of,  475 

treatment  of,  473 

•  by  radical  operation,  479 

palliative,  485 

varieties  of,  471 

of  Cowper's  gland,  752 

of  female  urethra,  663 


INDEX 


865 


Carcinoma  of  kidney,  i88 
of  prostate,  731 

of  renal  pelvis,  205 

of  seminal  vesicles,  751 

of  testicle,  791 

Caruncle,  urethral,  659 

Caseous  tuberculosis  of  kidney,  229 
Castration  causing  atrophy  of  prostate,  728 

in  tuberculosis  of  testicle,  786 

in  tumour  of  testicle,  794 

Cathelin's  separator,  367 
Catheter  fever,  566 

life,  705 

Catheterization  of  bladder,  353 
in  nervous  retention,  538 

of  prostatic  urethra,  675 

— —  in  enlarged  prostate,  698 

of  ureter  in  calculous  anuria,  282 

in  renal  fistula,  158 

in  tumour  of  renal  pelvis,  205 

•  — — •  in   ureteral  calculus,   328 

of  ureters,  305,  369 

in  congenital  absence  of  kidney, 

70 

in  hydronephrosis,  175 

in  misplaced  kidneys,  77 

in  p3-onephrosis,  148,  150 

■ ■  in  pyuria,  65 

■ — — ■  in  renal  tuberculosis,  235 

Catheters,  flexible,  354 
■ gum-elastic,   354 

metal,  354 

passage  of,  356 

• ■  rubber,  354 

sterilization  of,  354 

Cauterization  in  papilloma  of  bladder,  462 
Cavemositis,  fibrous,  848 

course  of,  850 

diagnosis  of,  850 

etiology  of,  848 

•  pathological  anatomy  of,  848 

• •  prognosis  in,  850 

•  ■  symptoms  of,  849 

treatment  of,  850 

Cerebral  disease,  bladder  symptoms  in,  536 
Chimney-sweep's  cancer,  831 
Chloride  test  of  renal  function,  22 
Cholesteatoma  of  bladder,  470 
Chondro-sarcoma  of  bladder,  488 
Chordee  in  gonorrhoea,  598 
Chorion-epithelioma  of  bladder,  488 
Chylocele  of  tunica  vaginalis,  816 
Chylous  haematocele  of  tunica  vaginalis, 816 
Chyluria,  65 
Circulatory  anuria,   16 
Circumcision,  837 

complications  of,  839 

■  in  incontinence  of  childhood,  381 

Colic,  renal,  260 

treatment  of,  268 

Colloid  bodies  in  renal  calculus,  250 
Congenital    abnormalities    {see   under    the 

various  organs) 
Conjunctiva,  infection  of,  by  gonococcus, 

597 
Connective-tissue  growths  of  bladder,  486 
Corpora  amylacea,  739 

cavernosa,  induration  of,  848 

Cowpefs  gland,  553,  752 

3d 


Cowper's  gland,  carcinoma  of,  752 

inflammation  of,  752 

new  growths  of,  663 

palpation  of,  555 

tuberculosis  of,  665 

Cowperitis,  752 

Cryoscopy  of  blood,  21 

of  urine,  20 

Cylindroma  of  Cowper's  glands,  663 
Cystectomy   in   carcinoma   of   bladder   in 

female,  484 
in  male,  483 

partial,  in  carcinoma  of  bladder,  479 

treatment  of  ureters  in,  483 

Cystic  embryoma  of  testicle,  791 
Cystin  calculi,  renal,  254 

vesical,  493 

Cystinuria,  etiology  of,  250 
Cystitis,  423 

acute,  treatment  of,  430 

bacteriology  of,  423 

chronic,   treatment  of,   432 

complicating  papilloma  of  bladder, 

459 

complications  of,  428 

cystoscopic  appearances  of,   424 

diagnosis  of,  428 

etiology  of,  423 

in  urethral  stricture,  626 

mode  of  infection  in,  424 

•  nervous,  533 

■  treatment  of,  539 

pathological  anatomy  of,  424 

prognosis  in,  430 

subacute,  treatment  of,  431 

symptoms  of,  426 

treatment  of,  430 

by  bladder  drainage,  433 

washing,  432 

by  continuous  irrigation,  435 

by  instillations,  433 

■  by  serums,  435 

by  vaccines,  435 

tuberculous  {see  Tuberculous  cystitis) 

Cystocele,  405 

diagnosis  of,  407 

etiology  of,  405 

prognosis  in,  408 

symptoms  of,  406 

treatment  of,  408 

urethral,  409 

varieties  of,  406 

Cystoprostatectomy  in  carcinoma  of  blad- 
der, 484 

Cystoscope,  catheter,  363 

irrigation,  362 

simple,  362 

Cystoscopic  appearance  of  normal  bladder, 

365 
Cystoscopy,  362 

direct,  364 

in  bilharziosis  of  bladder,  450 

in  calculous  anuria,  281,  282 

in  carcinoma  of  bladder,  477 

in  congenital  absence  of  kidney  and 

ureter,  69 

in  cystitis,  427 

in  enlarged  prostate,  699 

in  examination  of  prostate,  675 


866 


INDEX 


Cystoscopy  in  examination  of  ureter,  305 

in  hsematuria,  58 

in  hydronephrosis,  175 

in  pericj'stitis,  519,  520 

in  pyonephrosis,   148 

in  pyuria,  64 

in  renal  calculus,  263 

disease,  44 

■ —  papilloma,  460 

tuberculosis,  234 

in  rupture  of  bladder,  419 

in  tulaerculosis  of  prostate,  688 

in  tuberculous  cystitis,  438,  444 

in  tumour  of  renal  pelvis,  205 

in  ureteral  calculus,  328 

prolapse,  315 

in  vesical  calculus,  500 

in  vesico-intestinal  fistula,  526 

indirect,  362 

Cystotomy,  perineal,  541 

suprapubic     (see    Suprapubic     cyst- 

otomy) 
transperitoneal,     in     papilloma     of 

bladder,  468 
Cysto-uteropexy  in  urethral  cystocele,  410 
Cysts,  dermoid,  of  bladder,  488 

of  kidney,  207 

of  penis,  851 

— — -  of  testicle,  791 

hydatid,  of  kidney,  214 

• ■  course  of,  218 

• diagnosis  of,  217 

etiology  of,  215 

■ pathology  of,  216 

prognosis  in,  218 

symptoms  of,  216 

■  treatment  of,  218 

■  perivesical,  529 

■ of  prostate,  675 

of  urethra,  659 

sebaceous,  of  scrotum,  831 

■ solitary,  of  kidney,  22  r 

diagnosis  of,  213 

pathogenesis  of,  213 

pathology  of,  212 

prognosis  in,  214 

symptoms  of,  213 

treatment  of,  214 

urachal,  394 

Decapsulation  in  chronic  Bright's  disease, 
161 

in  haematogenous  pyelonephritis,  127 

in  puerperal  eclampsia,  163 

Dermato-ureterotresis,  341 
Dermoid  cysts  {see  Cysts,  dermoid) 
"  Diabetes,  phosphatic,"  50 
Dieffenbach's  operation  for  urethral  fistula, 

.654 
Dietl's  crises  in  movable  kidney,  85 
Difficult  micturition  (see  Micturition,  diffi- 
cult) 
DUatation  of  urethra,  630 

complications  of,  636 

congenital,  573 

continuous,  635 

in  chronic  urethritis,  615 

in  congenital  narrowing,  573 

in  hypospadias,  577 


Dilatation  of  urethra  in  stricture,  630 

spasmodic,  637 

intermittent,  633 

rapid,  635 

Discoid  kidney,  74 

Diuresis,  relation  of,  to  hydronephrosis,  170 

Diverticula  of  bladder,  411 

— ■ complications  of,  413 

diagnosis  of,  413 

etiology  of,  412 

pathological  anatomy  of,  411 

prognosis  in,  414 

symptoms  of,  412 

— ■ —  treatment  of,  414 

Double  bladder,  395 

penis,  836 

ureter,  312 

urethra,  570 

Drainage  of  bladder  (see  Bladder  drainage) 
Duplay's  operation  for  epispadias,  583 
for  penile  hypospadias,  580 

Ectopia  testis,  761,  763 

■  value  of  testicle  in,  764 

vesicae  (see  Extroversion  of  bladder) 

Egyptian  bilharziosis,  445,  451 
Electrical-conductivity  test  of  renal  func- 
tion, 23 
Electricity  in  atony  of  bladder,  539 

in  atrophy  of  prostate,   730 

in  chronic  prostatitis,  684 

in  fibrous  cavemositis,  851 

in  frequent  micturition,  377 

in  incontinence  of  childhood,  383 

in  papilloma  of  bladder,  461,  462 

in  prolapse  of  urethra,  586 

in  urethral  fistula,  653 

Elephantiasis  of  scrotum,  828 
Embryoma  of  testicle,  790 
Embryonic  adeno-sarcoma  of  kidney,  194 
Emissions,  nocturnal,  in  chronic  prostatitis, 

681 
Endothelioma  of  penis,  860 

of  testicle,  791 

Enlargement    of    prostate    (see    Prostate, 

enlarged) 
Enuresis  (see  Incontinence  of  urine) 

nocturnal  (see  Nocturnal  enuresis) 

Epididymectomy   in    tuberculosis    of    epi- 
didymis, 785 

Epididymis,  753 

encysted  hydrocele  of,  813 

Epididymitis,  771 

— —  complicating  enlarged  prostate,  701 

complications  of,  772 

etiology  of,  771 

■ operative  treatment  of,  774 

pathology  of,  771 

• sequelae  of,  772 

■ symptoms  of,  772 

•  syphilitic,  778 

• ■  treatment  of,  773 

tuberculous  (see  Tuberculosis  of  epi- 
didymis and  testicle) 
Epididymo-orchitis,  772,  776 
Epididymo-vasotom}',  771 
Epispadias,  582 

in  female,  583 

Epithelial  growths  of  bladder,  455 


INDEX 


867 


Epithelioma,  cylindrical,  of  bladder,  473 

of  penis,  852 

diagnosis  of,  856 

etiology  of,  852 

pathology  of,  854 

symptoms  of,  855 

treatment  of,  857 

of  scrotum,  831 

squamous,  of  Ijladder,  472 

of  male  urethra,  661 

Essential  enuresis,   380,  381 

Exposure  of  ureter  (see  Ureter,  exposure  of) 

"  Extravasation  of  urine,"  649 

Extroversion  of  bladder,   396 

etiology  of,  397 

• •  prognosis  in,  397 

• symptoms  of,  397 

■ • treatment  of,  398 

• • by  implantation  of  ureters 

into  rectum,   399 

by  Maydrs  operation,  401 

by  Segond's  operation,  399 

by  Sonnenberg's  opera- 
tion, 403 

by  Soubottine's  opera- 
tion, 400 

by  Trendelenburg's  opera- 
tion,  398 

■ by  Wood's  operation,  399 

Faradism  {see  Electricity) 

Fibrin  calculi,  renal,  254 

Fibrinous  hydrocele  of  tunica  vaginalis,  801 

Fibroma  of  bladder,  486 

of  kidney,   186 

of  tunica  vaginalis,  817 

Fibromatous  polypi  of  urethra,  658 
Fibro-myoma  of  bladder,  487 
Fibrous  cavernositis,  848 
Fistula,  suprapubic  vesical,  522 

etiology  of,  522 

treatment  of,  523 

urachal,  394 

ureteral,  316 

•  urethral,  651 

■  acquired,  651 

congenital,  651 

etiology  of,  651 

• symptoms  of,  652 

treatment  of,  653 

urethro-rectal,  652 

treatment  of,  655 

vesico-intestinal,  524 

course  of,  526 

diagnosis  of,   526 

etiology  of,   524 

pathology  of,  524 

■ —  prognosis  in,  526 

•  symptoms  of,  525 

— ■ — ■  treatment  of,   527 

vesico-vaginal,  527 

diagnosis  of,  528 

etiology  of,  527 

pathology  of,  528 

prognosis  in,  528 

symptoms  of,  528 

treatment  of,  528 

Fistula;,  perirenal,   134 

renal,  postoperative,   157 


Fistulas,  renal,  spontaneous,  156 

vesical,  421 

Fixation-of-complement  test  in  perivesical 
hydatid  cysts,  530 

in  renal  hydatid  cysts,  218 

Floating  kidney,  78 

Foreign  bodies  in  bladder,  514 

diagnosis  of,  515 

— —  effect  of,  on  bladder,  514 

— —  symptoms  of,  515 

treatment  of,  516 

■ in  urethra,  621 

Frequent     micturition     (see     Micturition, 

frequent) 
Freyer's  suprapubic  prostatectomy,  709 
Friedreich's  disease,  bladder  symptoms  in, 

536 
Fused  kidneys,  71 

Galactocele  of  tunica  vaginalis,  816 
Gall-bladder,  distended,  diagnosis  of,  from 

movable  kidney,  86 
Galvanism  (see  Electricity) 
Gangrene  of  foreskin  and  phimosis,  837 
Genital  tuberculosis,  685 
Gleet  (see  Urethritis,  chronic) 
Gonococcus,  history  of,  596 
Gonorrhoea,  596 

acute,  when  cured,  604 

and  marriage,  604 

causing  epididymitis,  771 

complications  of,  604 

diagnosis  of,  599 

•  symptoms  of,  597 

tests  for  cure  of,  604 

treatment  of,  abortive,  600 

prophylactic,  600 

Gonorrhoeal  arthritis,  605 

teno-synovitis,  606 

Gumma  of  testicle,  779 

Hasmatocele  of  spermatic  cord,  821 

of  tunica  vaginalis,  815 

complicating      hvdrocele, 

808 

spontaneous,   815 

traumatic,  815 

with  hydrocele,  815 

Haematogenous  pyelonephritis  (see   Pyelo- 
nephritis, haematogenous) 

■  tuberculosis  of  kidney,  227 

Haematuria,  55 

■  cystoscopy  in,  58 

diagnosis  of  cause  of,  59 

essential  renal,  59 

— — treatment  of,  60 

examination  of  blood  in,  57 

of  patient  in,  58 

in  aneurysm  of  renal  artery,  no 

in  bilharziosis  of  bladder,  450 

in  carcinoma  of  bladder,  475 

in  cystitis,  427 

in  enlarged  prostate,  697 

in  injury  to  kidney,  99 

■ in  malignant  growth  of  female  itre- 

thra,  663 
of  kidney,   195 

of  male  urethra,  661 

of  prostate,  734 


868 


INDEX 


Haematuria  in  papilloma  of  bladder,  458 

in  polycystic  kidney,  210 

in  prostatic  calculi,  741 

■ in  pyelonephritis,  122 

— ■ — ■  in  renal  abscess,  154 

• ■  — — -  calculus,  262 

— — ■ treatment  of,  268 

tuberculosis,  232,  235 

in  spermatocystitis,  745 

— ■ — ■  in  syphilis  of  bladder,  452 

in  tuberculosis  of  prostate,  687 

■  of  urethra,  665 

in  tuberculous  cystitis,  440 

in  ureteral  calculus,  326 

— — -  in  vesical  calculus,  497 

localization  of,  56 

tardive,  100 

treatment  of,  61 

types  of,  57 

vesical,  treatment  of,  61 

Haemospermia  in   acute  spermatocystitis, 

746 
Hermaphroditism,  835 
Hernia  of  bladder  (see  Cystocele) 

of  intestine   complicating   hydrocele 

of  tunica  vaginalis,  807 

of  misplaced  testicle,  765 

Hernial  sac,  hydrocele  of,  820 
Herpes  prsputialis,  845 
High-frequency   current    {see   under  Elec- 
tricity) 

Hilum  of  kidney,  4 

Horseshoe  kidney,  71 

Hydatid  cysts  (see  Cysts,  hydatid) 

Hydatids  of  Morgagni,  754 

Hydrocele  fluid,  805 

of  hernial  sac,  820 

of  spermatic  cord,  819 

of  testis  and  epididymis,  encysted,  813 

of  tunica  vaginalis,  800 

acute,  800 

fibrinous,  801 

in  infants,  802 

plastic,  801 

chronic,  802 

bilocular,  813 

complications       of, 

807 

congenital,  812 

■ diagnosis  of,  806 

etiology  of,  802 

infantile,  812 

pathology  of,  803 

• symptoms  of,  805 

treatment  of,  808 

by     auto  •  se- 
rums, 811 

by  operation, 

810 

•  by       tapping, 

809 
and    in- 
jection, 
810 

chylous,  816 

-— fatty,  816 

H3'dronephrosis,  164 

acquired,  165 

— —  catheterization  of  ureters  in,  175 


Hydronephrosis,  congenital,  164 
treatment  of,   177 

constant,  174 

course  of,  177 

cystoscopy  in,  175 

diagnosis  of,  175 

due  to  aberrant  vessels,  168 

■ — — ■ treatment  of,  178 

— — ■  to  calculus,  170 

treatment  of,  178 

to  movable  kidney,   169 

— ■ — • •  treatment  of,  178 

etiology  of,  164 

in  injury  to  kidney,  loi 

intermittent,  174 

pathological  anatomy  of,  172 

pathology  of,  165 

prognosis  in,  177 

— — •  symptoms  of,  173 

traumatic,  170 

treatment  of,  177 

tuberculous,  230 

with  renal  calculus,  256 

X-ray  examination  in,  42,  176 

Hydronephrotic  kidney,  functional  value 

of,  183 
Hypernephroma  of  kidney,  191 
Hypertonic  bladder,  531 
Hypertrophic  theory  of  cause  of  enlarged 

prostate,  690 
Hypospadias,  573 

etiology  of,  574 

glandular,  575 

operations  for,  579 

pathological  anatomy  of,  575 

penile,  576 

operations  for,  580 

perineal,  576 

operation  for,  582 

symptoms  of,  577 

treatment  of,  577 

Hysterical  anuria,  16 
■  polyuria,  13 

Implantation  of  ureter  into  intestine,  342, 

399 

into  rectum,  399 

into  skin,  341 

into  urethra,  403 

Impotence,  797 

atonic,  798 

organic,  797 

psychical,  797 

Incontinence  of  urine,  377 

due  to  bladder  spasm,  379 

'■ to  mechanical  causes,  378 

false,  378 

in  atrophy  of  bladder,  729 

in  childhood,  380 

etiology  of,  380 

prognosis  in,  381 

treatment  of,  381 

in  malignant  growth  of  female 

urethra,  663 

in  urethral  stricture,  627 

nervous,  532 

true,  378 

Indigo  calculi,  renal,  254 

vesical,  493 


INDEX 


869 


Indigo-carmine  test  of  renal  function,  25 
Induration  of  corpora  cavernosa,  848 
Infancy,  pyelitis  of,  141 
Infantile  hydrocele  of  tunica  vaginalis,  812 
Inflammatory  theory  of  enlarged  prostate, 

691 
Injuries  of  bladder,  416 

• of  kidney  with  external  wound,  106 

diagnosis  of,  107 
etiology  of,  106 
pathology  of,  106 
prognosis  in,  107 
symptoms  of,  107 

treatment  of,  107 

without  external  wound,  96 

complications     and 

sequelae  of,  100 

course  of,   103 

diagnosis  of,   102 

etiology  of,  96 

pathology  of,  96 

prognosis  in,   103 

repair  of,  98 

symptoms  of,  98 

— — treatment  of,  103 

•  of  penis,  841 

■  of  testicle,  756 

of  ureter,  308 

■ •  of  urethra,  588 

Intraperitoneal   haBmorrhage  in  injury  to 

kidne}',   10 1 
Inversion  of  bladder,  409 
Irrigation  of  bladder,  continuous,  in  cyst- 
itis, 435 

Jaboulay's    operation    for    hydrocele    of 

tunica  vaginalis,  811 
Jadassohn's  urinary  method,  611 
Janet's  irrigation  method,  613 

Kelly's  cystoscope  in  papilloma  of  bladder, 

461 
Kidney,  i 
■ abscess  of,  153 

absence  of,  congenital,  67 

clinical   aspects  of,    69 

exploration,  71 

actinomycosis  of,   245 

adenoma  of,  186 

atrophy  of,  congenital,  68 

clinical  aspects  of,  69 

attachments  of,  9 

bilharziosis  of,  246 

calculus  of  {see  Renal  calculus) 

carcinoma  of,  188 

congenital  abnormalities  of,  67 

cystic  {see  Polycystic  kidney) 

dermoid  cysts  of,  207 

discoid,  74 

exploration  of,  46 

fibroma  of,   186 

floating,  78 

— —  hilum  of,  4 
— - — -  horseshoe,  71 

— —  hydatid  cysts  of  (see  Cysts,  hydatid, 
of  kidney) 

hydronephrotic,  functional  value  of, 

183 

hypernephroma  of,  191 


Kldnev,  inflammation  of,  bacteriology  of, 
116 

classification  and  nomenclature 

of,  116 
{see  also  Nephritis,  Pyelitis,  Pye- 
lonephritis, Pyonephrosis) 
injuries  of  {see  Injuries  of  kidney) 

inspection  of,  31 

investment  of,  3 

leio-myoma  of,  187 

lipoma  of,  186 

lymphatics  of,  8 

misplaced  {see  Misplaced  Kidney) 

movable    {see   Movable   kidney) 

operations  on,  284 

palpation  of,  32 

polycystic  {see  Polycystic  kidney) 

relations  of,  i 

sarcoma  of,  189 

sigmoid,  74 

situation  of,   i 

solitary,  71 

cysts  of  {see  Cysts,  solitary,  of 

kidney) 

surgical  anatomy  of,  i 

syphilis  of,  247 

tuberculosis  of   {see  Tuberculosis  of 

kidney) 

tumours  of,  benign,  186 

differential  diagnosis  of,  36 

■ —  malignant,  187 

course  of,  199 

■  diagnosis  of,  199 

etiology  of,  188 
extension  of,  194 
histology  of,    188 
metastases  of,  194 
pathology  of,  188 
prognosis  in,   199 
symptoms  of,  195 
treatment  of,  by  nephrec- 
tomy, 200 
palliative,  200 

mixed,  194 

signs  of,  35 

X-ray  examination  of,  43,  199 

X-ray  examination  of,  37 

{see  also  Renal) 

Kidneys,  fused,  71 

supernumerary,  67 

Kollmann's  dilators,  616 

Lacunar  abscess,  605 

Lateral  anastomosis  in  hydronephrosis,  181 

Leio-myoma  of  kidney,   187 

Lipoma  of  kidney,  186 

of  spermatic  cord,  821 

of  tunica  vaginalis,  817 

Litholapaxy,  502 

contra-indications  of,  507 

dangers  of,  509 

difficulties  of,  507 

in  children,  506 

in  female,  507 

perineal,  509 

— ■ —  results  of,  512 
Lithotomy,  lateral,  511 

perineal,  511 

suprapubic,  510 


870 


INDEX 


Lithotomy,  suprapubic,  results  of,  513 

vaginal,  511 

Lithotrity  {see  Litholapaxy) 

Luys'   direct   cystoscope  in   papilloma  of 

bladder,  461 
in  tuberculous  cystitis,  444 

separator,  367 

'Lymph  scrotum,  828 

Lymphadenitis,  inguinal,  complicating  go- 
norrhoea, 605 

Lymphocele  of  tunica  vaginalis,  816 

Marsupialization  in  hydatid  cysts  of  kid- 
ney, 218 
Massage  of  prostate  in  chronic  prostatitis, 

683 
of  seminal  vesicles  in  chronic  sper- 

matocystitis,  748 
Maydl's    operation     for     extroversion     of 

bladder,  401 
Meatotomy    in    congenital    narrowing    of 

urethra,  572 
in  foreign  bodies  in  urethra,  622 

in  hypospadias,   577 

Meningitis,  spinal,  bladder  symptoms  in, 

535  ,      ., ,    j^ 

Metastases  of  malignant  growth  of  bladder, 

475 

of  kidney,  194 

of  penis,  855  . 

of  prostate,  733 
of  scrotum,  833 
of  testicle,  792 

of  urethra,  662 

Methylene-blue  test  of  renal  function,  23 
Micturition,  difficult,   384 

due  to  phimosis,  837 

functional,   385 

in  atrophy  of  bladder,  729 

•  in  chronic  prostatitis,  681 

in  enlarged  prostate,  697 

in  foreign  bodies  in  urethra,  622 

. in  malignant  growth  of  female 

urethra-,  663 

of  male  urethra,  661 

of  prostate,  733 

in  nervous  disease,  535 

of  bladder,  532 

in  prolapse  of  urethra,  585 

in  prostatic  abscess,  679 

calculi,  741 

in  tuberculosis  of  prostate,  688 

of  urethra,   665 

in  urethral  calculus,  620 

in  urethrocele,  587 

treatment  of,  385 

frequent,  374 

due  to  disease  of  bladder,  pros- 
tate, or  urethra,  376 

to  irritating  urine,  375 

to  phimosis,  837 

in  acute  prostatitis,  677 

•  spermatocystitis,  745 

in  atrophy  of  prostate,  729 

in  carcinoma  of  bladder,  475 

in  chronic   prostatitis,   680 

in  cystitis,  426 

in  enlarged  prostate,  696 

in  foreign  bodies  in  urethra,  622 


Micturition,  frequent,  in  malignant  growth 
of  female  ure- 
thra, 663 

. of  prostate,  733 

•  in  perivesical  hydatid  cysts,  530- 

•  in  prostatic  abscess,  679 

■  calculi,  741 

.  in  syphilis  of  bladder,  452 

•  in  tuberculosis  of  prostate,  687 

•  of  seminal  vesicles,  750 

■  of  urethra,   665 

in  tuberculous  cystitis,  439 

in  urethral  calculus,  620 

stricture,    627 

in  urethrocele,  587 

in  vesical  calculus,  497 

•  in  vesico-intestinal  fistula,  526' 

treatment  of,  376 

-with  normal  urine  and  bladder^ 

375 

■ with  polyuria,  374 

Miliary  tuberculosis  of  kidney,  228 
Misplaced  kidney,  74 

diagnosis  of,  76 

symptoms  of,  76 

treatment  of,  77 

testicle  {see  Testicle,  congenital  mal- 
position of) 
Monorchism,  756 
Monsarrat's  operation,   582 
Movable  kidney,  78 

anatomy  of,  78 

causing  hydronephrosis,   169 

diagnosis  of,  86 

from  distended  gall-blad- 
der, 86 

from  Riedel's  lobe,  86'    I 

from  tumour  of  large  in- 
testine, 87 

of  ovary,  87 

Dietl's  crises  in,  85 

due  to  injury,   102 

etiology  of,  80 

frequency  of,   80 

symptoms  of,  81 

gastro-intestinal,    85 

nervous,  85 

renal,  82 

treatment  of,  87 

— ■ operative,  91 

contra-indication  to. 


results  of,  94 

palliative,  88 

by  rest,  88 

contra-indication  to. 


* mechanical,    89 

selection  of  cases  in,  87 

Myoma  of  bladder,  487 
Myomatous  degeneration  of  tunica  vagi- 
nalis, 817 
Myxoma  of  bladder,  487 
Myxo-sarcoma  of  bladder,  488 

Nephrectomy,  293 

abdominal,  296 

by  morcellement,  295 

dangers  of,  296 


INDEX 


1 


Nephrectoniv  in  benign  growths  of  kidney, 

187' 
in  chronic  Bright's  disease,  i6i 

in  hydroneplirosis,  184 

in  injuries  of  kidney,  105 

of  ureter,  309 

in    malignant    giowths    of    kidney, 

200 

dangers  of,  202 

results  of,  202 

in  misplaced  kidney,  jy 

in  perinephritic  abscess,  115 

in  polycystic  kidney,  211 

in  pyelitis  of  pregnancy,  144 

in  pyelonephritis,  ascending,  136 

hematogenous,  127,  128 

in  pyonephrosis,  152  \ 

in  renal  actinomycosis,  246 

calculus,  276 

hydatid  cysts,  218 

syphilis,  248 

tuberculosis,  238 

after-results  of,  243 

immediate    mortality    of, 

242 

indications        for        and 

against,  239 

technique  of,  240 

treatment  of  ureter  after, 

241 

in  solitary  cysts  of  kidney,  214 

in  tumour  of  renal  pelvis,  206 

in  ureteral  fistula,  318 

lumbar,  293 

partial,  in  hydatid  cysts  of  kidney, 

218 
in  pyonephrosis,  152 

in  renal  tuberculosis,  238 

in  solitary  cyst  of  kidney,  214 

subcapsular,  295 

technique  of,  293 

Nephritis,  diathetic,  255 

due  to  renal  injury,  102 

non  -  suppurative,      acute,     surgical 

treatment  of,   160 
chronic,  surgical  treatment  of, 

160 
Nephro  -  cysto  -  anastomosis    in     hydrone- 
phrosis, 181 
Nephrolithotomy,  270 

compared  with  pyelolithotomy,  275 

dangers  of,  272 

results  of,  273 

Nephropexy  in  chronic  Bright's  disease,  161 

in  hydronephrosis,  179 

in  movable  kidney,  91 

technique  of,  91 

Nephrostomy  in  carcinoma  of  bladder,  484 

in  hydatid  cysts  of  kidney,  218 

in  hydronephrosis,   184 

in  papilloma  of  bladder, 

in  renal  fistula,  158 

technique  of,  290 

Nephrotomy  in  anuria,  20 

calculous,  283 

in  Bright's  disease,  160 

in  perinephritic  abscess, 

in  polycystic  kidney,  211 

in  puerperal  eclampsia,  163 


470 


"5 


Nephrotomy  in  pyelitis,  141 

of  pregnancy,  144 

in  pyelonephritis,  ascending,  133 

■ haematogenous,  127 

in  pyonephrosis,  150 

in  renal  tuberculosis,  244 

in  urethral  fever.  568 

technique  of,  290 

Nervous  cystitis,  533 
treatment  of,  539 

diseases  of  bladder,  531 

— —  symptoms  of,  531 

treatment  of,  538 

— — ■  polyuria,  13 

Nitze  operating  cystoscope,  461 
Nocturnal  emissions  in  chronic  prostatitis, 
681 

enuresis,  380 

due  to  phimosis,  837 

in  nervous  diseases,  535 

(Edema  of  penis,  846 
Oligospermia,  798 
Oliguria,  15 

in  injury  of  kidney,  100 

in  polycystic  kidney,  210 

Orchidectomy  in  misplaced  testicle,  769 
Orchidopexy  in  misplaced  testicle,  768 
Orchitis,  776 

and  mumps,  776 

•— — ■  syphilitic,  778 

typhoid,  -jjj 

Organic  impotence,  797 

Orthopaedic  resection  in  hydronephrosis, 
179 

Ovarian  tumour,  diagnosis  of,  from  mov- 
able kidney,  87 

Oxalate-of-lime  calculi,  renal,  253 

vesical,  491 

Oxaluria,  47 

etiology  of,  47,  249 

symptoms  of,  47 

treatment  of,  48 

Palpation  of  bladder,  352 

of  kidney,  32 

in  calculus,  262 

of  ureter,  303 

in  calculus,   327 

of  urethra,  555 

in  urethritis,  611 

Papilloma  of  bladder,  455 

complicating  bilharziosis,  451 

complications  of,   459 

course  of,   459 

cystoscopy  in,  460 

diagnosis  of,  460 

etiology  of,  454 

histological  appearance  of,  457 

malignant,    471 

pathology  of,   455 

prognosis  in,  459 

symptoms  of,  458 

treatment  of,  medicinal,  461 

operative,  461 
palliative,  468 

of  penis,  851 

of  renal  pelvis,  204 

of  urethra,  656 


872 


INDEX 


Paradidymis,  754 
Paraphimosis,  839 
"  Parrot  toQgue  "  in  pyelonepliritis,  131 

in  renal  failure,  11 

Partial  cystectomy,  479 

nephrectomy  {see  Nephrectomy,  par- 

tial) 

ureterectomy,  339 

Pawlik's  operation,  484 
Penis,  834 

absence  of,  836 

anatomy  of,  834 

congenital  malformations  of,  835 

dermoid  cysts  of,  851 

double,  836 

endothelioma  of,  860 

— —  epithelioma  of,   852 

• •  herpes  zoster  of,  845 

— - — ■  injuries  of,  841 
•  cedema  of,  846 

papilloma  of,  851 

rudimentary  development  of,  835 

sarcoma  of,  860 

torsion  of,  836 

tuberculosis  of,  665 

webbed,  836 

Pericystitis,  517 

diagnosis  of,  520 

etiology  of,  517 

pathology  of,  518 

■ prognosis  in,  520 

— — ■  symptoms  of,  518 

■ •  treatment  of,  521 

Perineal  cystotomy,  541 
drainage  of  bladder,  434 

litholapaxy  in  vesical  calculus,  509 

lithotomy  in  vesical  calculus,  511 

prostatectomy,  721 

in  atrophy,  730 

in  chronic  prostatitis,  684 

■  in  malignant  disease,  737 

• — — ■  in  prostatic  calculi,  743 

— - — •  results  of,  726 

Perinephritic  abscess,  112 

bacteriology  of,  112 

•  diagnosis  of,  114 

etiology  of,  112 

pathology  of,  113 

prognosis  in,   115 

symptoms  of,   113 

treatment  of,   115 

with  renal  calculus,  257 

Perinephritis,  iii 

forms  of.  III 

symptoms  of,  112 

treatment  of,   112 

with  renal  calculus,  256,  257 

Periprostatitis,  684 
Perirenal  fistulas,  154 

diagnosis  of,  155 

treatment  of,  156 

tumours,  220 

diagnosis  of,  222 

pathology  of,   220 

symptoms  of,  221 

— — -  treatment  of,  222 

Periurethral  abscess,  647 
Periurethritis,  647 

chronic  indurative,  650 


Periurethritis,  diffuse  phlegmonous,  649 
Perivesical  abscess,  517 

prognosis  in,  520 

symptoms  of,  519 

treatment  of,  521 

hydatid  cysts,  520 

Phenol-sulphone  -  phthalein  test    of  renal 

function,  27 
Phimosis,  836 

Phloridzin  test  of  renal  function,  27 
Phosphatic  calculi,  vesical,  491 

" diabetes,"  50 

Phosphaturia,  49 

etiology  of,  49,  249 

in  chronic  prostatitis,  681 

symptoms  of,  50 

treatment  of,  51 

Plastic  hydrocele,  801 
Pneumaturia,  66 

in  vesico-intestinal  fistula,  525 

Poliomyelitis,  anterior,  bladder  symptoms 

in,  536 
Polycystic  kidney,  208 

congenital  theory  of,  209 

diagnosis  of,  211 

■  etiology  of,  208 

inflammation  theory  of,  209 

neoplastic  theory  of,  210 

■ — —  pathology  of,  208 

prognosis  in,  211 

symptoms  of,  210 

treatment  of,  211 

tuberculosis  of  kidney,  230 

Polyneuritis,  bladder  symptoms  in,  536 
Polypi  of  urethra,  657 

Polyuria,  12 

frequent  micturition  with,   374 

— — ■  in  cystitis,  426 

in  hydronephrosis,   174 

in  injury  of  kidney,   100 

in  polycystic  kidney,  210 

in  pyelitis,  139 

in  pyelonephritis,  ascending,  133 

aseptic,  118 

■ •  haematogenous,  124 

■  in  renal  tuberculosis,  232,  234 

in  tuberculous  cystitis,  440 

in  ureteral  calculus,  326 

nervous  or  hysterical,  13 

Pregnancy,    pyelitis    of    {see    Pyelitis    of 

pregnancy) 
Preputial  calculus,  843 
Priapism,  847 
Prolapse  of  bladder,  409 

of  ureter,  315 

of  urethra,  585 

Prostate,  667 

absence  of,  675 

arteries  of,  671 

atrophy  of,  728 

diagnosis  of,  729 

• etiology  of,  728 

pathological  anatomy  of,  728 

• symptoms  of,  729 

treatment  of,"  730 

carcinoma  of,  731 

congenital  malformations  of,   675 

•  — — -  cystoscopic  examination  of,  675 

cysts  of,  675 


INDEX 


873 


Prostate,  enlarged,  690 

age -incidence  of,  691 

bladder  changes  in,  695 

catheter  life  in,  705 

complications  of,  699 

treatment  of,  703 

course  of,  701 

diagnosis  of,  701 

etiology  of,  690 

adenomatous  theory,  690 

arterio-sclerotic      theory, 

690 

hypertrophic  theory,  690 

inflammatory  theory,  691 

urethral     gland     theory, 

691 

—  examination  in,  698 

nature  of,  690 

pathological  anatomy  of,  692 

prognosis  in,  701 

symptoms  of,  696 

treatment  of,  operative,  707 

■ — •  palliative,  703 

urethral  changes  in,  694 

lymphatics  of,  673 

malignant  disease  of,  731 

diagnosis  of,  735 

etiology  of,  731 

histology  of,  731 

pathological  anatomy  of, 

731 

■ symptoms  of, -733 

■  treatment   of,    operative, 

736 

•  palliative,  735 

nerves  of,  673 

rectal  examination  of,  673 

sarcoma  of,  733 

surgical  anatomy  of,  667 

tuberculosis  of,  685 

veins  of,  672 

Prostatectomy,  choice  of  method  of,  726 

in  enlarged  prostate,  707 

in  nervous  retention,  539 

perineal  {see  Perineal  prostatectomy) 

suprapubic   (see   Suprapubic   prosta- 
tectomy) 

Prostatic  abscess,  679 
course  of,  679 

— ■ — •  prognosis  in,  679 

treatment  of,  679 

calculi,  classes  of,  739 

calculus,  739 

complicating  enlarged  prostate, 

701 

diagnosis  of,  742 

etiology  of,  739 

symptoms  of,  741 

treatment  of,  742 

Prostatismus,  690 
Prostatitis,  acute,  677 

course  of,  678 

prognosis  in,  678 

symptoms  of,   677 

treatment  of,  678 

chronic,  G80 

bacteriology  of,  682 

diagnosis  of,  682 

etiology  of,  680 


Prostatitis,  clironir,  pathology  of,  G80 
prognosis  in,   683 

- — —  symptoms  of,  680 

treatment  of,  683 

Prostatorrhoea  in  chronic  prostatitis,  681 
Psychical  impotence,  797 

Puerperal  eclampsia,  surgical  treatment  of, 

163 
Pyelitis,   138 

calculous,  with  renal  calculus,  264 

diagnosis  of,  139 

— ■ — -  etiology  of,  138 

of  infancy,  141 

diagnosis  of,   142 

prognosis  in,   142 

symptoms  of,   141 

treatment  of,  142 

of  pregnancy,  142 

course  of,  143 

diagnosis  of,  143 

operative  treatment  of,   144 

pathology  of,  142 

prognosis  in,  143 

prophylaxis  in,   143 

symptoms  of,   143 

vaccine  treatment  of,  143 

pathology  of,  138 

symptoms  of,  138 

treatment  of,  140 

urine  changes  in,  139 

vaccine  treatment  of,  140 

Pyelography,  42 

in  horseshoe  kidney,  73 

in  hydronephrosis,  176 

in  misplaced  kidney,  77 

Pyelolithotomy,  273 

compared  with  nephrolithotomy,  275 

results  of,  274 

Pyelonephritis,  ascending,  128 
acute,  non -operative  treatment 

of,  135 
operative    treatment    of, 

135 
•  pathology  of,   129 

prophylaxis  in,  134 

symptoms  of,  131 

chronic,     operative    treatment 

of,   136 

pathology  of,  130 

prophylaxis  in,    136 

■ symptoms  of,  132 

■  ■ vaccine  treatment  of,  137 

•  diagnosis  of,  134 

•  — —  etiology  of ,  128 

■  pathology  of,   129 

prognosis  in,  134 

sclerotic,  pathology  of,  131 

symptoms  of,  131 

treatment  of,  134 

aseptic,  117 

due  to  excretion  of  irritants,  117 

to  retention  of  urine,  117 

to     urinary    obstruction, 

117 
•  symptoms  of,  iiS 

treatment  of,  119 

haematogenous,   119 

acute,   122 

chronic,  124 


874 


INDEX 


Pyelonephritis,    haematogenous,    diagnosis 
of,  125 

etiology  of,   120 

fulminating  cases  of,  124 

medicinal  treatment  of,   126 

mild  form  of,  122 

nephrectomy  in,  127,  128 

nephrotomy  in,  127 

pathology  of,  120 

prognosis  in,  126 

serum  treatment  of,  126 

• symptoms  of,  122 

■ vaccine  treatment  of,  126 

• infective,  119 

of  pregnancy    {see    Pyelitis  of   preg- 

nancy) 

with  renal  calculus,  257 

Pyeloplication  in  hydronephrosis,  179 
Pyelotomy  in  calculous  anuria,  283 
Pyelo-ureteral    anastomosis    in    hydrone- 
phrosis, 181 
Pyonephrosis,  144 

course  of,  148 

cystoscopy  in,  148 

diagnosis  in,  148 

etiology  of,  144 

pathology  of,   145 

prognosis  in,   148 

■ symptoms  of,  146 

— —  treatment  of,  150 

with   renal   calculus,    257,    264 

X-ray  examination  in,   42,  150 

Pyuria,  62 

catheterization  of  ureters  in,   65 

cystoscopy  in,  64 

■ •  examination  of  urine  in,  62 

• — • — ■  in  cystitis,  427 

in  perinephritic  abscess,  114 

in  pyonephrosis,  147 

in  renal  calculus,  262 

in  syphilis  of  bladder,  452 

in  urethral  calculus,   620 

localization  of,  64 

types  of,  63 

X-ray  examination  in,  65 

Radiant  heat  in  frequent  micturition,  377 

in  gonorrhoeal  rheumatism,  606 

Radiography  (see  X-ray  examination) 
Radium-therapy  in  malignant  disease  of 
prostate,  736 

in  papilloma  of  bladder,  461 

Rectal  examination  in  acute  prostatitis,  678 

spermatocystitis,  746 

in  chronic  prostatitis,  682 

spermatocystitis,  747 

urethritis,    611 

in  enlarged  prostate,  698 

in  periprostatitis,  684 

in  periurethral  abscess,  648 

in  perivesical  hydatid  cysts,  530 

in  prostatic  abscess,  679 

atrophy,  728 

calculus,  742 

malignant  disease,  734 

tuberculosis,   688 

in  tuberculosis  of   seminal  ve- 
sicle, 750 
^  in  urethral  calculus,  620 


Rectal  examination  in  urethral  malignant 
growth,  661 

rupture,  591 

in  vesical  calculus,  499 

carcinoma,  477 

papilloma,  460 

■ of  bladder,  352 

■  of  Cowper's  glands,  555 

■ of  prostate,  673 

of  urethra,  556 

Referred  pain  in  renal  calculus,  261 
Reflex  anuria,  16 

Renal  artery,  6 

aneurysm  of  {see  Aneurysm  of 

renal  artery) 

calculi,  chemical  composition  of,  252 

•  position  of,  43 

shape,  size,  and  number  of,  254 

structure  of,  252 

• ■  X-ray  examination  of,  38,  263, 

264 

calculus,  249 

bilateral,  276 

— causing  hydronephrosis,  170 

complications  of,   263 

condition  of  kidney  in,  41 

course  of,  263 

diagnosis  of,   38,   264 

dietetic  treatment  of,  267 

etiology  of,  249 

examination  in,  262 

in  solitary  kidney,  276 

operative  treatment  of,  269 

pathology  of,  255 

prognosis  in,  264 

prophylaxis  in,  267 

— quiescent,  259 

symptoms  of,  259 

treatment  of,  268 

colic,  260 

treatment  of,  268 

disease,  cystoscopy  in,  44 

failure  with  enlarged  prostate,  700 

signs  and  symptoms  of,  10 

fistulae,  postoperative,  157 

spontaneous,  156 

function,  10 

examination  of,  10 

test  of,  by  chlorides,  22 

•  by  cryoscopy,  20 

■  by  electrical  conductivity, 

23 

■ by  indigo-carmine,  25 

■ by  methylene-blue,  23 

by        phenol  -  sulphone  - 

phthalein,  27 

by  phloridzin,  27 

by  toxicity  of  urine,  27 

infarcts,  250  .^ 

pedicle,  9 

pelvis,  4 

estimation  of  capacity  of,  175 

inflammation  of,  116 

tumours  of,  204 

diagnosis  of,  205 

etiology  of,  204 

pathology  of,  204 

prognosis  in,  206 

symptoms  of,  205 


INDEX 


875 


Renal  pelvis,  tumours  of,  treatment  of,  206 

with  renal  -calculus,  257 

X-ray  examination  of,  37 

tuberculosis     (see     Tuberculosis     of 

kidney) 

veins,  8 

{see  also  Kidney) 

Reno-ureteral  colic  in  renal  tuberculosis, 

232 
Rete  testis,  753 
Retention  of  urine,  385 
causing  aseptic  pyelonephritis, 

117 

complicating  cystitis,  428 

tuberculous,   440 

■ diagnosis  of,   386 

due  to  phimosis,  837 

etiology  of,  385 

hysterical,   385 

in  acute  prostatitis,  678 

in  chronic  prostatitis,  681 

in  nervous  diseases,  535 

in  periurethral  abscess,  648 

in  perivesical  hydatid  cyst,  530 

in  prostatic  calculi,  741 

enlargement,  697 

■ —  in  urethral  calculus,  620 

■ fever,  567 

■ — • —  foreign  bodies,  622 

malignant    growths,    56 1, 

663 

stricture,  627 

tuberculosis,  665 

in  vesical  calculus,  497 

foreign  bodies,  515 

papilloma,  459 

nervous,  532 

treatment  of,  538 

treatment  of,   387 

Rhabdo-myoma  of  bladder,  488 
Rhabdo-myo-sarcoma  of  kidney,   194 
Rheumatism,  gonorrhoeal,  605 

Riedel's  lobe  of  liver,  diagnosis  of,   from 

movable  kidney,  86 
Rupture  of  bladder,  416 

diagnosis  of,  418 

etiology  of,  416 

pathology  of,  416 

symptoms  of,  417 

treatment  of,  419 

— —  of  urethra,  589 

•  course  of,  590 

diagnosis  of,  591 

•  in  injury  of  penis,  842 

mortality  in,   593 

■  pathological  anatomy  of,  589 

prognosis  in,  591 

symptoms  of,  590 

treatment  of,  592 

Russell's  (Hamilton) "  stole  "  operation,  5S1 

Salvarsan  in  bilharziosis  of  bladder,  451 

in  S5'philis  of  kidney,  247 

Sarcoma  of  bladder,  487 

of  female  urethra,  663 

of  kidney,   189 

of  male  urethra,  661 

of  misplaced  testicle,  763 

of  penis,  860 


Sarcoma  of  prostate,  733 

of  seminal  vesicles,  752 

of  testicle,  791 

of  tunica  vaginalis,  817 

Schistosomum  ha;matobium,  445 
Sclerosis,  amyotrophic,  bladder  symptoms 

in,  536 

multiple,    bladder      symptoms     in. 

Scrotal  hernia,  diagnosis  of  hydrocele  from, 

806 
Scrotum,  828 

elephantiasis  of,  828 

lymph,  828 

new  growths  of,  831 

Sebaceous  cysts  of  scrotum,  831 
Segond's  operation,  399 
Seminal  vesicles,  744 

absence  of,  744 

anatomy  of,  744 

concretions  of,  752 

•  congenital  anomalies  of,  744 

multiple,  745 

— ■ new  growths  of,  751 

■ tuberculosis  of,   749 

Separation  of  urines  by  catheters,  369 

by  separators,  367 

choice  of  instrument  for,  372 

Separator,  Cathelin's,   367 

Luys',  367 

method  of  using,   367 

Septicaemia,  urinarv,  due  to  catheter  life, 

708 

in  pyelonephritis,   133 

Serum  treatment  of  bacilluria,  55 

of  cystitis,  435 

of   pyelonephritis,  haeraatogen 

ous,   126 

of  urethral  fever,  568 

Sigmoid  kidney,  74 

Sodium-urate  calculi,  renal,  254 

Solitary  kidney,  71 

Sonnenberg's  operation,  403 

Soot  wart,  832 

Soubottine's  operation,  400 

Spasm  of  bladder  {see  Bladder  spasm) 

Spermatic  cord,  819 

hsematocele  of,  821 

hydrocele  of,  819 

new  growths  of,  821 

volvulus  of,  819 

Spermatocele,  813 
Spermatocystitis,  745  . 

acute,  complications  of,  746 

course  of,  746 

etiology  of,  745 

pathology  of,   745 

symptoms  of,  745 

treatment  of,  746 

chronic,  diagnosis  of,  747 

etiology  of,  745 

pathology  of,  745 

symptoms  of,  746 

treatment  of,  747 

Spermatorrhoea  in  chronic  vesiculitis,  747 
Spina  bifida,  bladder  symptoms  in,  536 
Spinal  meningitis,  bladder  symptoms  in,  535 
"  Stammering  "  bladder,  385 

Sterilitv,  798 


876 


INDEX 


Stricture  of  urethra,  623 

annular,   625 

bridle,  625 

causing    difficult    micturition, 

384 

retention,  390 

complications  of,  629 

diagnosis  of,  628 

due  to  phimosis,  837 

etiology  of,  623 

•  examination  in,  628 

•  multiple,  624 

■ pathological  anatomy  of,  623 

•  prognosis  in,  630 

spasmodic,  628 

dilatation  in,  637 

■ symptoms  of,  626 

■  treatment  of,  by  dilatation,  630 

by  operation,  637 

choice  of,  645 

urethroscopy  in,  628 

Sturt's  rite,  653 

Suggestion  treatment  of  frequent  micturi- 
tion, 377 

of  incontinence   of   childhood, 

384 

Supernumerary  kidneys,  67 

Suprapubic  cystotomy,  542 

after-treatment  of,  542 

dangers  of,  544 

in  hypospadias,  582 

in  partial  obliteration  of  ure- 
thra, 570 

in  pyelonephritis,  ascending,i35 

in  tuberculous  cystitis,  444 

in  urethral  cystocele,  410 

■  fever,  568 

in  vesical  carcinoma,  486 

foreign  bodies,  516 

haematuria,  61 

papilloma,  463 

■ in  vesico-intestinal  fistula,  527 

in  vesico-vaginal  fistula,  529 

transverse,  546 

drainage  of  bladder  in  cystitis,  434 

in  tuberculosis  of  pros- 
tate, 689 

■ lithotomy  in  vesical  calculus,  510 

■ prostatectomy,  709 

dangers  and  complications  of, 

716 

■ in  prostatic  calculi,  743 

■ •  malignant  disease,  736 

results  of,  720 

• surgical  anatomy  of,  712 

— — ■  vesical  fistula,  522 

Suprarenal  capsules,  3 

extract  in  rupture  of  penile  urethra, 

592 

■ gland,  tumours  of,  223 

diagnosis   of,  225 

■ etiology  of,  223 

nomenclature  of,  223 

■ ■ prognosis  in,  225 

■ symptoms  of,  224 

■ — —  treatment  of,   225 

Syme's  operation  for  urethral  stricture,  643 
Syphilis  of  bladder,  452 

of  kidney,  246 


Syphilitic  epididymitis,  778 

orchitis,  778 

Tabes  dorsalis,  bladder  symptoms  in,  535 
Tapping  of  hydrocele,  808 
Teno-synovitis,  gonorrhoeal,  6o5 
Testicle,  753 

absence  of,  756 

anatomy  of,  753 

atrophy  of,  755 

after  orchitis,  yjj 

congenital  malposition  of,  761 

complications  of,  764 

etiology  of,  761 

■ •  pathological  anatomy  of, 

761 

•  symptoms  of,  764 

— ■ — ■ treatment  of,  767 

— by      orchidectomy, 

769 
by  orchidopexy,  768 
by   replacement   in 
abdomen,  769 

descent  of,  754 

ectopic,  761,  763 

— value  of,  764 

•  encysted  hydrocele  of,  813 

• •  imperfectly  descended,  761 

• value  of,  764 

injuries  of,  756 

inversion  of,  770 

lymphatics  of,  754,  794 

new  growths  of,  789 

• ■  classification  of,  789 

■ diagnosis  of,  793 

— — ■  • from  hydrocele,  807 

etiology  of,  789 

■ pathology  of,  789 

symptoms  of,  792 

treatment  of,  794 

strapping  of,  in  epididjTnitis,  775 

syphilis  of,  778 

torsion  of,  758 

tuberculosis  of  {s.ee  Tuberculosis  of 

epididymis  and  testicle) 

• veins  of,  754 

• ■  wounds  of,  757 

Thiersch  operation  for  epispadias,  583 
Thiersch -Gould    operation    for   malignant 
growth  of  penis. 


857 

of  urethra,  662 
of    examination 


of 


Thompson's    method 
urine,  610 

Thyroid  extract  in  incontinence  of  child- 
hood, 383 

Torsion  of  penis,  836 

— —  of     spermatic     cord     in     misplaced 
testicle,  767 

of  testicle,  758 

Toxicity-of-urine  test  of  renal  function,  27 

Trabeculation     of     bladder     in     nervous 
disease,  534 

Transperitoneal    cystotomy   in    papilloma 
of  bladder,  468 

Trendelenburg's    operation    for    extrover- 
sion of  bladder,  398 

Tuberculin  treatment  of  penile  tuberculosis, 
666 


INDEX 


877 


Tuberculin  treatment  of   prostatic   tuber- 
culosis, 689 

of  renal  tuberculosis,  236 

of      tuberculosis      of      seminal 

vesicles,  751 

of  tuberculous  cystitis,  443 

epididymitis,  784 

Tuberculosis  of  epididymis  and  testicle,  781 

clinical  varieties  of,  782 

complications  of,  783 

— —  course  of,  783 

diagnosis  of,  783 

—  etiology  of,  781 

pathology  of,  781 

prognosis  in,  783 

symptoms  of,  782 

treatment    of,    choice   of, 

787 

non-operative,  784 

•  operative,  785 

— — • tuberculin,  784 

• •  genital,  685 

■ of  kidney,  bilateral,  231 

caseous,  229 

climatic  treatment  of,  238 

•  course  of,  233 

■ •  diagnosis  of,  234 

etiology  of,  228 

examination  in,  233 

lesions  of  kidney  in,  230 

of  perirenal  tissues  in,  231 

of  renal  pelvis  in,  230 

of  ureter  in,  231 

medicinal  treatment  of,  238 

method  of  infection  in,  226 

miliary,  228 

operative  treatment  of,  238 

pathological  anatomy  of,  228 

polycystic,  230 

prognosis  in,  233 

■ symptoms  of,  231 

■ tuberculin  treatment  of,  236 

ulcero-cavemous,  229 

■ X-ray  examination  in,  43,  236 

of  penis,  665 

of  prostate,  683 

■  etiology  of,  686 

• •  pathology  of,  687 

—  prognosis  in,  688 

■ symptoms  of,  687 

treatment  of,  689 

of  seminal  vesicle,  749 

of  urethra,  665 

Tuberculous  cystitis,  437 

complications  of,  440 

■ course  of,  440 

■ •  diagnosis  of,  441 

•  etiology  of,  437 

pathology  of,  438 

prognosis  in,  440 

symptoms  of,  439 

treatment  of,  general,    443 

local,  444 

hydronephrosis,  230 

Tubuli  recti,  753 

seminiferi,  753 

Tumours  of  bladder,  454 

• of  kidney  and  ureter,   ibC 

of  misplaced  testicle,  765 


Tumours  of  penis,  851 

of  scrotum,  831 

of  spermatic  cord,  821 

of  testicle,  789 

of  tunica  vaginalis,  817 

of  urethra,  656 

perirenal,  220 

suprarenal,   223 

Tunica  albuginea,  753 

vaginalis,  800 

hasmatocele  of,  815 

hydrocele  of  (see  Hydrocele  of 

tunica  vaginalis) 

new  growths  of,  817 

spermatocele  of,  813 

Ulcero-cavernous   tuberculosis  of  kidney, 

229 
Urachus,  cysts  of,  394 

fistula  of,  394 

Ureter,  299 

abnormalities  of,  congenital,  67,  312 

absence  of,  congenital,  67 

bilharziosis  of,  246 

blood-vessels  of,  302 

examination  of,   by  catheterization, 

305 

by  cystoscopy,  305 

by  inspection,  303 

by  palpation,  303 

by  X-rays,  305 

exposure  of,  335 

extraperitoneal,  335 

parasacral,  337 

transperitoneal,  337 

transvesical,  338 

vaginal,  338 

vesical,  338 

fistula  of,  316 

implantation  of,  into  intestine,  342, 

399 

into  rectum,  399 

into  skin,  341 

into  urethra,  403 

injuries  of,  308 

narrowing  of,  congenital,  314 

operations  on,  334 

physiology  of,  302 

prolapse  of,  314 

relations  of,  300 

surgical  anatomy  of,  299 

wounds  of,  309 

Ureteral  anastomosis  in  injury  of  ureter, 
309 

in  wounds  of  ureter,  310 

(see  also  Anastomosis) 

calculi,  shape,  size,  and  number  of,  321 

calculus,  319 

course  of,  326 

diuretic  treatment  of,  330 

examination  in,  by  cystoscopy, 

328 

• —  by  palpation,  327 

by  sounding,  32S 

•  by  X-rays,  329 

pathology  of,  319 

position  of,  320 

prognosis  in,  326 

symptoms  of,  323 


INDEX 


Ureteral    calculus,    treatment    of,   instru- 
mental, 331 

operative,  331 

Ureterectomy,  339 

in  tumour  of  renal  pelvis  and  ureter, 

206 

partial,  339 

Uretero-appendicostomy,  342 
Uretero-cysto-neostomy  in  fistula  of  ureter, 

317 

• in  wounds  of  ureter,  311 

Uretero-intestinal  anastomosis,  342 
Uretero-pyelo-neostomy  in  hydronephrosis, 

181 
Uretero-pyeloplasty  in  hydronephrosis, 182 
Uretero-rectal  anastomosis,  399 
Uretero-renal  anastomosis,  339 
Ureterostomy  in  papilloma  of  bladder,  470 
Ureterotomy  in  calculous  anuria,  283 
Uretero -ureteral  anastomosis,   340 

•  in  hydronephrosis,   180 

Uretero -vesical  anastomosis,  340 
Ureters,  catheterization  of  {see  Catheteriza- 
tion of  ureters) 
Urethra,  550 
absence  of,  congenital,  569 

anatomy  of,  surgical,  550 

calibre  of,  552 

caruncle  of,  659 

congenital  malformations  of,  569 

cysts  of,  659 

development  of,  392 

■  dilatation  of  (see  Dilatation  of  ure- 
thra) 

• double,  570 

examination  of,  555 

by  inspection,  555 

by  palpation,  555 

by  sounds,  556 

by  urethroscopy,  556 

-female,  554 

examination  of,  562 

malignant  growths  of,  663 

■  foreign  bodies  in,  621 

inflammation  of  {see  Urethritis) 

■  injuries  of,  588 

length  of,  550 

lymphatics  of,  554 

■ malignant  growths  of,  659 

course  of,  662 

diagnosis  of,  662 

pathological  anatomy  of, 

660 

symptoms  of,  661 

■ treatment  of,  662 

narrowing  of,  congenital,  572 

obliteration  of,  569 

partial,  569 

papilloma  of,  657 

polypi  of,  657 

prolapse  of,  585 

rupture  of  {see  Rupture  of  urethra) 

stricture  of  {see  Stricture  of  urethra) 

structure  of,  553 

tuberculosis  of,  665 

wounds  of,  588 

Urethral  calculus,  618 

etiology  of,  618 

pathology  of,  618 


Urethral  calculus,  symptoms  of,  620 

treatment  of,  621 

cystocele,  409 

drainage  of  bladder,  433 

fever,  566 

— ■ due    to    internal    urethrotomy^ 

641 

treatment  of,  568 

— with  suppression  of  urine,  567 

without   suppression   of    urine, 

566 

fistula  {see  Fistula,  urethral) 

gland  theory  of  enlarged  prostate,  691 

instrumentation,  asepsis  in,  562 

shock,  565 

Urethritis,  594 

acute  gonococcal  {see  Gonorrhoea) 

and  marriage,  616 

auto-infective,  607 

bacteriology  of,  595 

chronic,  608 

•  diagnosis  of,  610 

dilatation  in,  615 

— ■ —  etiology  of,  608 

—  examination  of  discharge  in, 612 

of  urine  in,  610 

history  of,  610 

■ instillations  in,  614 

irrigation  in,  613 

palpation  in,  611 

pathology  of,  608 

rectal  examination  in,  612 

symptoms  of,  609 

■ treatment  of,  613 

urethroscopy  in,  612 

•  non-gonococcal,  septic,  606 

Urethrocele,  586 
Urethro-rectal  fistula,  652 

treatment  of,  655 

Urethroscopy,  556 

in  chronic  urethritis,  612 

in  periurethral  abscess,  648 

in  urethral  calculus,  621 

cysts,  659 

foreign  bodies,  622 

malignant    growths,    661 

papilloma,  657 

polypi,  659 

stricture,  628 

tuberculosis,  665 

technique  of,  559 

Urethrotomy,  external,  in  chronic  indura- 
tive urethritis,   650 

in  stricture,  643 

in  urethral  calculus,   621 

internal,  in  chronic  indurative  peri- 
urethritis, 650 

in  periurethral  abscess,  649 

in  stricture,  638 

after -results  of,  641 
dangers    and    difficulties 
of,  640 
—  results  of,  641 

in  urethral  tuberculosis,  666 

Uric  acid,  derivation  of,  250 
Uric-acid  calculi,  renal,  253,  254 

vesical,  491 

"  Urinary  abscess,"  647 
fever,  566 


INDEX 


879 


Urinary  obstruction    causing  aseptic  pye- 
lonephritis, 117 

in  liydronephrosis,   165 

in  pyelonepliritis,  ascending,i35 

in  pyonephrosis,  144 

in  renal  calculus,  263 

(see  also  Anuria) 

septicaimia  due  to  catheter  life,  708 

in  pyelonephritis,   133 

tension  anuria,   i<S 

Urine,  abnormal  conditions  of,  47 

blood  in  [see  HaMuaturia) 

crystals  in,  249 

examination  of,  11,  46,  372 

"  extravasation  "  of,  649 

incontinence  of  (see  Incontinence  of 

urine) 
of  each  kidney,  examination  of,  372 

separation  of,  367 

quantity  of,  12 

retention  of  (see  Retention  of  urine) 

specific  gravity  of,  11 

urea  in,  12 

uric  acid  in,  250 

Uronephrosis  (see  Hydronephrosis) 
Uro-pyonephrosis,   144 

with  renal  calculus,  257 

Vaccine  treatment  of  bacilluria,  55 

of  cystitis,  435 

•  of  gonorrhoeal  rheumatism,  606 

of  prostatic  tuberculosis,   689 

of  pyelitis,   140 

of  pregnancy,   143 

of  pyelonephritis,  ascending,i37 

haematogenous,   126 

of  spermatocystitis,  chronic,  748 

of  tuberculosis  of  prostate,  689 

of  urethral  fever,  568 

Vagini^/  ,;xamination  in  vesical  calculus, 499 
carcinoma,  477 

of  bladder,  353 

Varicocele,  822 

and  misplaced  testicle,  767 

etiology  of,  823 

in  malignant  tumour  of  kidney,  198 

prognosis  in,  825 

symptoms  of,  824 

treatment  of,  825 

varieties  of,  823 

Vas  aberrans,  754 

deferens,  754 

Vasa  efferentia,  753 
Vesical  calculus,  490 

chemical  composition  of,  491 

complicating  bilharziosis,  450 

• cystoscopy  in,  500 

diagnosis  of,  498 

etiology  of,  490 

examination  of  bladder  in,  499 

fixed,  495 

pathology  of,  496 

■  physical  characters  of,  491 

sounding  in,  499 

symptoms  of,  496 


Vesical  calculus,  treatment  of,  500 

by  litholapaxy,  502 

by  litJKjtomy,  510 

choice  of  operation  in,  511 

—  X-ray  examination  in,  500 

crises  in  nervous  disease  of  bladder, 

531 

ha;maturia,  treatment  of,  61 

(see  also  under  Bladder) 

Vesico-intestinal  fistula,  524 
Vesico -vaginal  fistula,  527 
Vesiculitis  (see  Spermatocystitis) 
Vesiculotomy  in  chronic  spermatocystitis, 

748 
Villous  tumour  of  bladder  (see  Papilloma 

of  bladder) 
Volvulus  of  spermatic  cord,  819 
of  testicle,  758 

Wart,  soot,  of  scrotum,  832 

(see  also  Papilloma) 

Webbed  penis,  836 

Wheelhouse's  operation  for  urethral  stric- 
ture, 643 

Wolbarst's  method  of  examination  of  urine, 
611 

Wood's  operation  for  extroversion  of 
bladder,   399 

Wounds  of  bladder,  420 

diagnosis  of,  421 

prognosis  in,  421 

symptoms  of,  421 

treatment  of,  422 

of  kidney,  106 

of  penis,  842 

of  testicle,  757 

of  ureter,  309 

of  urethra,  589 

Xanthin  calculi,  renal,  254 

■  vesical,  493 

X-ray  examination,  dangers  of,  44 

in  calculous  anuria,  28  r 

in  fibrous  cavernositis,  850 

in  hydronephrosis,   42,    176 

■ in  prostatic  calculi,  742 

in  pyelitis,   140 

in  pyonephrosis,  42,  150 

in  pyuria,  65 

in  renal  calculus,  38,  263,  264 

tuberculosis,  43,  236 

tumours,  43,   199 

in  ureteral  calculus,  329 

prolapse,  316 

in  urethral  calculus,  621 

in  vesical  calculus,  500 

foreign  bodies,  516 

of  bladder,  360 

of  kidney,  37 

of  ureter,  305 

treatment    of    frequent    micturition, 

377 

Young's  perineal  operation  for  malignant 
disease  of  prostate,  737 


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London,  E.C. 


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